Recurrent abdominal pain: a psychogenic disorder?

It's Not Cyclic Vomiting Syndrome Until Dietl's is Ruled Out: A Case for Point of Care Renal Ultrasound

BACKGROUND

Abdominal pain and vomiting are frequent complaints for pediatric patients presenting to the Emergency Department (ED). When a diagnosis such as chronic abdominal pain, cyclic vomiting, or abdominal migraine has previously been made, it can lead to diagnostic momentum and confirmation bias on behalf of the treating physician. Dietl's crisis is a commonly missed diagnosis in the pediatric population that presents with intermittent episodes of pain and vomiting. It can be readily diagnosed at the bedside by the emergency physician (EP) through the employment of point of care ultrasound (POCUS).

CASE SERIES

We present two cases of pediatric patients with episodic abdominal pain and vomiting who were previously diagnosed with cyclic vomiting syndrome. In both cases, pediatric gastroenterology evaluations had occurred with negative diagnostic testing having been performed. Both patients also presented to their primary pediatrician and the ED multiple times with each encounter resulting in treatment of symptoms and discharge. Each patient eventually presented to the ED when an EP was present who performed a renal POCUS. In each patient, the POCUS revealed severe unilateral hydronephrosis. Subsequent workup confirmed the diagnosis of Dietl's crisis as the etiology of symptoms. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In pediatric patients, EPs should be wary of the diagnosis of cyclic vomiting syndrome until ureteral obstruction has been ruled out. A bedside POCUS can rapidly establish this diagnosis and potentially preclude recurrent health care visits, unnecessary diagnostic testing, and permanent loss of renal function.

Abdominal migraine and cyclical vomiting syndrome

Abdominal migraine and cyclical vomiting syndrome (CVS) are characteristic syndromes which have overlapping characteristics with migraine but lack the cardinal symptom of headache. Both abdominal migraine and CVS are characterized by recurrent attacks of nausea, vomiting, and/or abdominal pain lasting hours to a few days, with symptom freedom between attacks. Both abdominal migraine and CVS typically occur in children and adolescents, who often go on to develop more typical migraine headaches when older, but may also present for the first time in adults. Due to their shared characteristics and association with migraine headaches, abdominal migraine and CVS are sometimes called "migraine equivalents," and their pathophysiology is assumed to overlap with migraine headache. This chapter describes what is known about the clinical characteristics, epidemiology, pathophysiology, and prognosis of abdominal migraine and CVS, and explores their relationship to migraine. We also review the existing evidence for the nonpharmacological management, acute treatment of attacks, and preventive treatments for both abdominal migraine and CVS.

A 7-Year-Old Boy With Recurring Episodes of Abdominal Pain

Recurrent abdominal pain is a relatively common complaint in children who present to the emergency department. The etiology is often thought to be psychogenic, with an underlying organic cause present in less than 10% of patients. Intermittent ureteropelvic junction obstruction is usually not considered in the differential diagnosis of recurrent acute abdominal pain in children, which can cause a significant delay in diagnosis. In this condition, intermittent obstruction of the flow of urine from the renal pelvis to the proximal ureter occurs, which causes intermittent acute colicky abdominal pain and vomiting. This acute event, often referred to as a Dietl's crisis, either subsides after several hours or prompts a visit to the emergency department. Management often focuses on the identification of psychosocial issues or constipation, and routine abdominal imaging is not a common practice. The frequency of these events over time and the duration of each acute event are 2 components that factor into determining the loss of function in the affected kidney. The purpose of this case report is to increase awareness of intermittent ureteropelvic junction obstruction as a cause of recurring episodes of acute abdominal pain in children. Emphasis in this case report is on Dietl's crisis, how it presents, and how it is diagnosed and managed.

Pioneer Paper: An Accidental Scientist: Chance, Failure, Risk-Taking, and Mentoring

I never intended to become a scientist. My career developed on the basis of chance happenings, repeated failure, the willingness to take risks and the acceptance and provision of mentoring. My career has included periods of difficulty and shifted back and forth between academic health centers and universities in Canada. Although I have been amply recognized for my successes, my greatest learning has come from my failures. My greatest satisfaction has been in the development, evaluation and dissemination of interventions. The combination of intellectual stimulation and emotional gratification has meant a rewarding career.

Recurrent Abdominal Pain

The purpose of this article is to provide an empirically informed but clinically oriented overview of behavioral treatment of recurrent abdominal pain. The epidemiology and scope of recurrent abdominal pain are presented. Referral process and procedures are discussed, and standardized approaches to assessment are summarized. Treatment protocols developed by Sanders and colleagues and by Finney and colleagues are described, followed by a review of treatment efficacy. The article concludes with practice recommendations that emphasize the importance of reassurance and education, appropriate and realistic treatment goals, the child's daily functional status, and treatment plans tailored to match the child and family's presentation.

Behavioural Treatment of Childhood Recurrent Abdominal Pain: Relationships Between Pain, Children's Psychological Characteristics and Family Functioning

This study examined the impact and side effects of a cognitive behavioural program for the treatment of recurrent abdominal pain (R.A.P.) on children's behavioural adjustment and family functioning. It assessed the extent to which changes in children's pain symptoms covaried with family processes thought to be etiologically significant in cases of R.A.P. Results showed that pain symptoms of both experimental and control children improved significantly six months after initial assessment. Treatment achieved its objectives more quickly with a higher proportion of completely pain-free children. None of the measures of child adjustment or family conflict, expressiveness, independence or achievement orientation were associated with changes in pain intensity ratings or parent observational measures of pain behaviour. There was no evidence that treatment was associated with any negative side effects.

Annual research review: functional somatic symptoms and associated anxiety and depression--developmental psychopathology in pediatric practice

BACKGROUND

Medically unexplained physical symptoms, commonly referred to as functional somatic symptoms (FSS), are common in pediatric medical settings and associated with suffering, impairment, and medical help seeking. The association of pediatric FSS with anxiety and depressive symptoms and disorders across the life span is reviewed.

METHOD

Review and critique of controlled studies examining cross-sectional and longitudinal associations of FSS with anxiety and depressive symptoms and disorders in community-based and clinical samples of children and adolescents.

RESULTS

FSS are consistently associated cross-sectionally with anxiety and depressive symptoms and disorders in childhood and adolescence, and the likelihood of associated anxiety and depression increases with the number of reported FSS. The presence of one or more FSS early in life is associated with an increased likelihood of multiple FSS and anxiety and depressive symptoms and disorders later in life, and anxiety and depressive symptoms and disorders in childhood are associated with subsequent multiple FSS.

CONCLUSION

Strong associations between FSS, anxiety, and depression across the life span suggest the need to reconsider existing nosology and reconceptualize symptomatic relationships. Large, population-based longitudinal studies of FSS, anxiety, and depressive symptoms and disorders are needed to establish temporal relationships between the various symptoms and conditions.

Do Parents Maintain or Exacerbate Pediatric Functional Abdominal Pain? A Systematic Review and Meta-analysis

Parents may maintain or exacerbate functional abdominal pain (FAP) in children through modeling of physical symptoms and solicitous responses to the child’s complaints. This systematic review and meta-analysis aimed to examine these relationships. Parents of children with FAP reported more physical symptoms than parents of healthy children (effect size d = .36). As all studies were cross-sectional or retrospective, the causal direction was unclear. For parental responses to child complaints, not enough studies were available to perform a meta-analysis. We conclude that the present literature is unfit to establish whether parents maintain or exacerbate pediatric FAP through the processes investigated.

Anxiety and pain symptoms in children with inflammatory bowel disease and functional gastrointestinal disorders undergoing colonoscopy

OBJECTIVE

To compare pain and anxiety scores between children with inflammatory bowel disease (IBD) and those with functional gastrointestinal disorders (FGID) undergoing colonoscopy and to examine the role of anxiety and procedure length in predicting reports of pain.

MATERIALS AND METHODS

Children ages 10 to 18 years undergoing colonoscopy (general anesthesia) for the first time completed pain and anxiety questionnaires immediately before the procedure and a pain questionnaire 48 hours after colonoscopy. The diagnosis was determined by chart review and physician interview.

RESULTS

Children with FGID had a longer duration of pain than those with IBD. Children with FGID endorsed a greater total number of the pain descriptors. The FGID group reported higher usual pain severity and greater postprocedural pain. No differences in anxiety were reported. However, higher levels of anxiety were associated with higher pain scores at the time of colonoscopy in children with IBD. It required significantly more time to perform colonoscopy in the IBD group than in the FGID group. Longer procedure duration was positively correlated with pain in children with FGID but not in children with IBD.

CONCLUSIONS

Children with FGID report more usual pain symptoms and may describe more pain after a colonoscopy when compared with children with IBD. Anxiety appears to play a role in pain severity after colonoscopy in children presenting with IBD, but not in children with FGID.

Dietl's crisis: an under-recognized clinical entity in the pediatric population

OBJECTIVE

To characterize and determine whether patients with recurrent abdominal symptoms and associated ureteropelvic junction obstruction (UPJO) (Dietl's crisis) are effectively treated by pyeloplasty and to determine criteria for evaluating UPJO in childhood abdominal pain.

MATERIALS AND METHODS

A retrospective chart review from 1998 to 2001 was performed to identify patients with Dietl's crisis and associated UPJO. Chart review included presenting symptoms, location of lesion, condition of the affected renal unit, referral method, and surgery success.

RESULTS

Eight patients (7 male and 1 female) were identified with Dietl's crisis. All eight were initially misdiagnosed and spent at least a year with significant pain symptoms before being properly diagnosed. Only one patient had associated urologic complaints. Renal scan split functions of the affected renal unit ranged from 34% to 51%. One nephrectomy and seven pyeloplasties were performed and resolution of all patients' abdominal symptoms, including pain, resolved.

CONCLUSIONS

Children with Dietl's crisis often suffer a delay in diagnosis; the clinical entity appears to be under-diagnosed. Renal parenchyma is typically preserved, and there is a paucity of associated urologic complaints. Once properly diagnosed, patients are well served by a pyeloplasty. Children with periumbilical pain and vomiting, particularly males, would benefit from ultrasound imaging.

Chronic abdominal pain in children

Chronic abdominal pain, defined as long-lasting intermittent or constant abdominal pain, is a common pediatric problem encountered by primary care physicians, medical subspecialists, and surgical specialists. Chronic abdominal pain in children is usually functional, that is, without objective evidence of an underlying organic disorder. The Subcommittee on Chronic Abdominal Pain of the American Academy of Pediatrics and the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition has prepared this report based on a comprehensive, systematic review and rating of the medical literature. This report accompanies a clinical report based on the literature review and expert opinion. The subcommittee examined the diagnostic and therapeutic value of a medical and psychological history, diagnostic tests, and pharmacologic and behavioral therapy. The presence of alarm symptoms or signs (such as weight loss, gastrointestinal bleeding, persistent fever, chronic severe diarrhea, and significant vomiting) is associated with a higher prevalence of organic disease. There was insufficient evidence to state that the nature of the abdominal pain or the presence of associated symptoms (such as anorexia, nausea, headache, and joint pain) can discriminate between functional and organic disorders. Although children with chronic abdominal pain and their parents are more often anxious or depressed, the presence of anxiety, depression, behavior problems, or recent negative life events does not distinguish between functional and organic abdominal pain. Most children who are brought to the primary care physician's office for chronic abdominal pain are unlikely to require diagnostic testing. Pediatric studies of therapeutic interventions were examined and found to be limited or inconclusive.

Chronic Abdominal Pain In Children: a Technical Report of the American Academy of Pediatrics and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Chronic abdominal pain, defined as long-lasting intermittent or constant abdominal pain, is a common pediatric problem encountered by primary care physicians, medical subspecialists and surgical specialists. Chronic abdominal pain in children is usually functional-that is, without objective evidence of an underlying organic disorder. The Subcommittee on Chronic Abdominal Pain of the American Academy of Pediatrics and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition has prepared this report based on a comprehensive, systematic review and rating of the medical literature. This report accompanies a clinical report based on the literature review and expert opinion. The subcommittee examined the diagnostic and therapeutic value of a medical and psychologic history, diagnostic tests, and pharmacological and behavioral therapy. The presence of alarm symptoms or signs (such as weight loss, gastrointestinal bleeding, persistent fever, chronic severe diarrhea and significant vomiting) is associated with a higher prevalence of organic disease. There was insufficient evidence to state that the nature of the abdominal pain or the presence of associated symptoms (such as anorexia, nausea, headache and joint pain) can discriminate between functional and organic disorders. Although children with chronic abdominal pain and their parents are more often anxious or depressed, the presence of anxiety, depression, behavior problems or recent negative life events does not distinguish between functional and organic abdominal pain. Most children who are brought to the primary care physician's office for chronic abdominal pain are unlikely to require diagnostic testing. Pediatric studies of therapeutic interventions were examined and found to be limited or inconclusive.

Recurrent abdominal pain, anxiety, and depression in primary care

OBJECTIVE

The prevalence of psychiatric disorder in children and adolescents with functional recurrent abdominal pain (RAP) is unknown. Our aim was to determine whether RAP is associated with psychiatric symptoms and disorders, anxious temperament, and functional impairment in pediatric primary care.

METHODS

Children and adolescents who were 8 to 15 years of age, inclusive, and presented with RAP (N = 42) or for routine care in the absence of recurrent pain (N = 38) were identified by a screening procedure in pediatric primary care office waiting rooms and recruited to participate in a case-control study. Outcome measures were psychiatric diagnoses generated by standardized psychiatric interview administered blind to subject status and self, parent, and clinician ratings of child psychiatric symptoms, temperamental traits, and functional status.

RESULTS

RAP patients were significantly more likely to receive a diagnosis of a psychiatric disorder, with a categorical anxiety disorder in 33 (79%) and a depressive disorder in 18 patients (43%), and higher levels of anxiety and depressive symptoms, temperamental harm avoidance, and functional impairment than control subjects. Anxiety disorders (mean age of onset: 6.25 [standard deviation: 2.17] years) were significantly more likely to precede RAP (mean age of onset: 9.17 [standard deviation: 2.75] years) in patients with associated anxiety.

CONCLUSIONS

Youths who present with RAP in primary care deserve careful assessment for anxiety and depressive disorders. Future studies should examine treatments that are proved to be efficacious for pediatric anxiety and/or depressive disorders as potential interventions for RAP. Longitudinal, family, and psychobiological studies are needed to illuminate the nature of observed associations among RAP, anxiety, and depression.

Psychosocial factors and childhood recurrent abdominal pain

Recurrent abdominal pain in children is not a single condition but a description of a wide spectrum of clinical manifestations, some of which fit into a definite pattern, such as the irritable bowel syndrome, while others do not. Organic disorders may be present, but in the majority of children they cannot be detected. Although children with recurrent abdominal pain do not generally have psychological or psychiatric illness, there is a growing body of evidence to suggest that psychosocial stress plays an important role in this condition. This review will look into some of this evidence. The precise pathophysiology that results in abdominal pain is still not clearly understood, but the current belief is that visceral hypersensitivity or hyperalgesia and changes in the brain-gut axis linking the central and enteric nervous systems are important mechanisms.

Abdominal migraine: evidence for existence and treatment options

There is evidence to suggest that, in children, episodic abdominal pain occurring in the absence of headache may be a migrainous phenomenon. There are four separate strands of evidence for this: the common co-existence of abdominal pain and migraine headaches; the similarity between children with episodic abdominal pain and children with migraine headaches, with respect to social and demographic factors, precipitating and relieving factors, and accompanying gastrointestinal, neurological and vasomotor features; the effectiveness of nonanalgesic migraine therapy (such as pizotifen, propanolol, cyproheptadine and the triptans) in abdominal migraine; and the finding of similar neurophysiological features in both migraine headache and abdominal migraine. Abdominal migraine is rare, but not unknown, in adults. Many families are content with a diagnosis and reassurance that the episodes, though distressing, are not the result of serious pathology. Some patients respond to simple dietary and other prophylactic measures. There is scant evidence on which to base recommendations for the drug management of abdominal migraine. What little literature exists suggests that the antimigraine drugs pizotifen, propanolol and cyproheptadine are effective prophylactics. Nasal sumatriptan (although not licensed for pediatric use) may be effective in relieving abdominal migraine attacks.

Childhood experience of illness as a risk factor for medically unexplained symptoms

Clinical experience suggests that a high proportion of patients with medically unexplained symptoms or somatoform disorders give histories of adverse childhood experiences. Previous work has reported that both personal and family experience of illness may be associated with later unexplained symptoms in the individual. Most of this research is subject to recall bias. This review explores data from the UK Medical Research Council National Survey of Health and Development, a population-based birth cohort study. The main finding of this work is that childhood experience of illness in parents is an independent risk factor for later unexplained symptoms. Personal experience of illness has a more complicated relationship. There is no evidence that severe physical disease in childhood is associated with later unexplained symptoms, but common childhood unexplained symptoms are predictors of symptoms in adulthood.

Pharmacological interventions for recurrent abdominal pain (RAP) in childhood

BACKGROUND

Between 4% and 25% of school age children complain of recurrent abdominal pain (RAP) of sufficient severity to interfere with daily activities. For the majority of such children no organic cause for their pain can be found on physical examination or investigation. Although most children are likely managed by reassurance and simple measures, a large range of interventions has been recommended.

OBJECTIVES

To determine the effectiveness of medication for recurrent abdominal pain in school-age children.

SEARCH STRATEGY

The Cochrane Library (CENTRAL), MEDLINE, EMBASE, CINAHL, ERIC, PsycLIT, LILACS and JICST were searched using a strategy combining (Recurrent OR synonyms) AND (Abdomen OR synonyms) AND (Pain OR synonyms). Where appropriate search filters were employed. In addition, researchers working in this area were asked to identify relevant studies.

SELECTION CRITERIA

Any study in which the majority of participants were school age children fulfilling standard criteria for RAP, and who were allocated by random or quasi-random methods to any drug treatment compared with a placebo or no treatment.

DATA COLLECTION AND ANALYSIS

References identified by the searches were screened against the inclusion criteria by two independent reviewers.

MAIN RESULTS

Only one trial met the inclusion criteria. This cross-over trial in 14 children who met suggested criteria for "abdominal migraine" compared pizotifen and placebo, each given for one month with no washout period. Participants reported a mean of 8.21 (95% CI 2.93, 13.48) fewer days of pain while taking the active drug. They also reported that the mean difference on an "Index of Severity" was -16.21 (95% CI -26.51, -5.90) and on an "Index of Misery" was -56.07 (95% CI -94.07, -18.07).

REVIEWER'S CONCLUSIONS

There is little evidence to suggest that recommended drugs are effective in the management of RAP. At present there seems little justification for the use of these drugs other than in clinical trials. There is an urgent need for trials of all suggested pharmacologic interventions in children with RAP.

The relation of daily stressors to somatic and emotional symptoms in children with and without recurrent abdominal pain

Prior investigations of the relation between stressors and symptoms in children with recurrent abdominal pain (RAP) have focused on major negative life events. This study used consecutive daily telephone interviews to assess daily stressors and symptoms in 154 pediatric patients with RAP and 109 well children. Results showed that patients with RAP reported more frequent daily stressors than well children reported both at home and at school. Idiographic (within-subject) analyses indicated that the association between daily stressors and somatic symptoms was significantly stronger for patients with RAP than for well children. In contrast, the relation between daily stressors and negative affect did not differ between the groups. The relation between daily stressors and somatic symptoms was stronger for patients with RAP who had higher levels of trait negative affectivity.

The prognosis of childhood abdominal migraine

AIMS

To determine the clinical course of childhood abdominal migraine, seven to 10 years after the diagnosis.

METHODS

A total of 54 children with abdominal migraine were studied; 35 were identified from a population survey carried out on Aberdeen schoolchildren between 1991 and 1993, and 19 from outpatient records of children in the same age group who had attended the Royal Aberdeen Children's Hospital. Controls were 54 children who did not have abdominal pain in childhood, matched for age and sex, obtained from either the population survey or the patient administration system. Main outcome measures were presence or resolution of abdominal migraine and past or present history of headache fulfilling the International Headache Society (IHS) criteria for the diagnosis of migraine.

RESULTS

Abdominal migraine had resolved in 31 cases (61%). Seventy per cent of cases with abdominal migraine were either current (52%) or previous (18%) sufferers from headaches that fulfilled the IHS criteria for migraine, compared to 20% of the controls.

CONCLUSIONS

These results support the concept of abdominal migraine as a migraine prodrome, and suggest that our diagnostic criteria for the condition are robust.

The relation of daily stressors to somatic and emotional symptoms in children with and without recurrent abdominal pain

Prior investigations of the relation between stressors and symptoms in children with recurrent abdominal pain (RAP) have focused on major negative life events. This study used consecutive daily telephone interviews to assess daily stressors and symptoms in 154 pediatric patients with RAP and 109 well children. Results showed that patients with RAP reported more frequent daily stressors than well children reported both at home and at school. Idiographic (within-subject) analyses indicated that the association between daily stressors and somatic symptoms was significantly stronger for patients with RAP than for well children. In contrast, the relation between daily stressors and negative affect did not differ between the groups. The relation between daily stressors and somatic symptoms was stronger for patients with RAP who had higher levels of trait negative affectivity.

Recurrent abdominal pain in children--a retrospective study of outcome in a group referred to a pediatric gastroenterology practice

Recurrent abdominal pain (RAP) affects a significant number of children each year. We reviewed our experience over a 2-year period to determine the outcome of patients who were referred for pediatric gastroenterology consultation. We identified 356 patients, 149 (42%) male and 207 (58%) female. All patients underwent a thorough interview and complete physical examination. Patients suspected of having irritable bowel syndrome (IBS) were treated as such without further initial evaluation. Others underwent an initial blood and urine evaluation. When these initial screening studies were negative, additional studies were performed including abdominal ultrasonography, radiography, and/or endoscopy of the upper gastrointestinal (GI) tract if the history suggested a possible diagnosis that could be excluded or confirmed by such tests. There was no identifiable diagnosis in 43.5% of the patients studied. IBS was diagnosed in 25.8% of all patients. Constipation was diagnosed in 3.7%. Miscellaneous causes, including GI mucosal lesions, and renal and pancreatic disorders were found in an additional 27% of patients. In a follow-up survey, more than 70% of the treated respondents were improved (i.e., their RAP had resolved or was markedly improved). We conclude that most children with RAP have a functional disorder. Patients with an organic cause for pain can be identified and treated in a cost-effective manner with carefully planned evaluation.

Pain in the very preterm baby: 'suffer little children?'

Increases in medical expertise and technological advances have enabled the survival of very preterm babies who form a new and growing population. Comparisons between the foetus, full-term baby and the very preterm baby indicate that by the time the foetus is of 23 weeks gestation, many of the abilities, for example, sensing touch, hearing, seeing, moving and even learning may be common to all three. Thus, the very preterm infant who has been described as a unique organism, is not passive, but is a sentient being who is unlikely to survive without the medical and technical support of the Neonatal Intensive Care Unit (NICU) where he/she is exposed to frequent and regular medical procedures. Many of these procedures would be, for any normal, fully developed human being at best uncomfortable and at worst painful. Reviews within the past 10 years have shown that the neurochemical, anatomic and functional systems of newborns are developed enough to perceive pain. More importantly, rat pup studies have indicated that not only may the very preterm baby experience pain but it may experience it more intensely than the more mature infant. Moreover, there may be serious consequences of repeated painful medical intervention. Alleviation of pain and/or distress in very preterm infants is, therefore, an important issue.

Recurrent abdominal pain in children: a review of psychological factors and treatment

This paper reviews current knowledge regarding recurrent abdominal pain (RAP) and the physiological, dietary, and psychological variables that may have some influence in pain episodes. Emphasis is placed on psychological factors and studies that have investigated psychological treatment modalities. There is some limited evidence of physiological dysfunction in RAP patients, and while some researchers have asserted that RAP may be a dietary disorder, results of several studies do not support this assertion. Studies examining psychological variables in RAP patients show elevated anxiety levels; however, elevated anxiety is also associated with organic abdominal pain. Psychological treatments focusing on cognitive-behavioral methods have demonstrated success in treating RAP. Follow-up studies are needed to determine the long-term success of these treatments, and continued research examining which children benefit from treatment would also be beneficial.

Abdominal pain and irritable bowel syndrome in adolescents: a community-based study

OBJECTIVES

This study was undertaken to determine (1) the prevalence of gastrointestinal symptoms including abdominal pain in a community-based population of adolescents, (2) whether a subgroup of these subjects have symptoms resembling Irritable bowel syndrome (IBS), and (3) whether anxiety and depression are more commonly found in adolescents with IBS-type symptoms compared with unaffected adolescents.

METHODS

We collected data by administration of a gastrointestinal symptoms questionnaire, State-Trait Anxiety Inventory, and Children's Depression Inventory to middle school and high school students.

RESULTS

A total of 507 subjects participated (mean age of middle school students 12.6 years; mean age of high school students 15.6 years). Abdominal pain was noted by 75% of all students. The pain occurred weekly in 13% to 17% of the subjects and was severe enough to affect activities in approximately 21%. Irritable bowel syndrome-type symptoms were noted by 17% of high school students and 8% of middle school students (p <0.01) who reported abdominal pain (n = 381), representing 14% and 6% of all high school and middle school students (p <0.005), respectively. Anxiety and depression scores were significantly higher for students with IBS-type symptoms compared with those without symptoms. Eight percent of all students had seen a physician for abdominal pain in the previous year. These visits were correlated with abdominal pain severity, frequency, duration, and disruption of normal activities but not with anxiety, depression, gender, family structure, or ethnicity.

CONCLUSION

Recurrent abdominal pain and symptoms of IBS are commonly noted in a community-based adolescent population and frequently result in use of health care resources. Health care providers who work with this age group need to be able to recognize the symptom complex associated with IBS, as well as the possible relationship to anxiety and depression.

Psychological barriers to optimal pain management in infants and children

OBJECTIVE

To discuss the numerous psychological barriers to optimum pain relief in infants, children, and adolescents.

DATA SOURCES

The professional and scientific literature on pediatric pain was accessed by means of Psychlit and Medline searches. Our clinical experience with patients was also used.

DATA SYNTHESES

The potential barriers to optimum management were discussed in terms of cognitive and emotional developmental barriers, perceived lack of control, children's knowledge and attitudes, and characteristics of children.

CONCLUSIONS

The psychological barriers to optimum pain relief are significant and attention to these barriers could lead to better pain management.

Prevalence and clinical features of abdominal migraine compared with those of migraine headache

The prevalence and clinical features of migraine headache and abdominal migraine were studied in the well defined population of Aberdeen schoolchildren. Ten per cent of all children (2165) aged 5-15 years were given a questionnaire inquiring, among other symptoms, about the history of headache and abdominal pain over the past year. A total of 1754 children (81%) responded. Children with at least two episodes of severe headache and/or sever abdominal pain, attributed by the parents either to unknown causes or to migraine, were invited to attend for clinical interview and examination. After interview, 159 children fulfilled the International Headache Society's criteria for the diagnosis of migraine and 58 children had abdominal migraine giving estimated prevalence rates of 10.6% and 4.1% respectively. Children with abdominal migraine had demographic and social characteristics similar to those of children with migraine. They also had similar patterns of associated recurrent painful conditions, trigger and relieving factors, and associated symptoms during attacks. The similarities between the two conditions are so close as to suggest that they have a common pathogenesis.

Somatization in children and adolescents

OBJECTIVE

To review the empirical literature on somatization in the pediatric age group, emphasizing prevalence, influence on health care utilization, issues in the development of somatization, comorbidity with other psychiatric disorders, assessment, and treatment.

METHOD

One hundred nineteen studies and reports addressing medically unexplained somatic symptoms in children and adolescents were compiled via MEDLINE search and extensive cross-referencing. All available controlled studies were included, as were selected case reports and collections of cases. Selected citations from the adult literature were chosen for relevance to pediatric somatization.

RESULTS

Recurrent, medically unexplained physical symptoms are common in the pediatric age group, are often associated with other psychiatric symptoms, and may represent a common presentation of psychiatric disorder in the primary care setting. DSM-III-R-defined somatization disorder is rare, and pseudoneurological symptoms are unusual. Patients may be at risk for potentially dangerous, costly, and unnecessary medical investigations and treatments, and they may excessively utilize health care services.

CONCLUSION

Our current understanding of pediatric somatization and its consequences is limited. Collaboration between mental health professionals and primary health care providers is essential. Consistent terminology, developmentally appropriate classification, and systematic future research will be necessary for the development of successful prevention and treatment strategies.

Early pain experience, child and family factors, as precursors of somatization: a prospective study of extremely premature and fullterm children

In a prospective study of 36 children who were extremely low birthweight (ELBW: < 1000 g) preterm infants and 36 matched full-term controls, differences were found in somatization at age 4 1/2 years. Only children who had been extremely premature, and thereby experienced prolonged hospitalization and repeated medical intervention in infancy, had clinically high somatization scores on the Personality Inventory for Children. The combination of family relations at age 4 1/2 years, neonatal intensive care experience, poor maternal sensitivity to child cues in mother-child interaction observed at age 3 years, and child avoidance of touch or holding at age 3, predicted somatization scores, prior to school entry. Due to the known higher incidence of actual medical problems among children with a history of extreme prematurity, the high somatization ELBW children were compared with the normal somatization ELBW children. There were no differences in prevalence of actual medical problems between the 2 ELBW groups, and the importance of maternal factors in relation to somatization was confirmed. Child temperament at age 3, but not personality at 4 1/2, was related to somatization. The etiology of recurrent physical complaints of no known medical cause appears to be a multi-dimensional problem. Non-optimal parenting may contribute to the development of inappropriate strategies for coping with common pains of childhood, or of chronic pain patterns, in some children who have experienced prolonged or repeated pain as neonates.

Psychologic perspectives on pediatric pain

Pain has always been a salient feature for children because it occurs frequently in their everyday lives. We are only beginning to understand childhood pain. Yet, it is this understanding that influences our assessment and treatment of their pain. As with adults, pain in children is a complex matrix of biologic, psychologic, and sociologic phenomena. This article reviews what we know today about childhood pain and focuses on the psychologic perspectives that affect that pain experience. It outlines the psychologic elements that include: cognition, coping strategies, ability to communicate pain, fear, temperament, and personality as well as the sociologic factors, such as the family, culture, and economics, that influence children's perceptions and reactions to pain. The article concludes with a review of psychologic treatments of pain and an exploration of the effects of the psychology of adults, including professional anxiety and beliefs about pain and medication, on how pain is experienced by children.

The prevalence of Helicobacter pylori serum antibodies in children with recurrent abdominal pain

As part of a large, prospective study we investigated the prevalence Helicobacter pylori serum antibodies in children with recurrent abdominal pain (RAP). All patients suffered from recurrent bouts of abdominal pain for at least 6 months and ranged in age from 6 to 12 years. H. pylori antibodies were detected using an enzyme-linked immunosorbent assay. The prevalence of H. pylori antibodies in the RAP group was compared to that of a control group which consisted predominantly of pre-operative children. None of the control group suffered or had suffered from RAP. Antibodies to H. pylori were found in 7 of 82 (8.5%) RAP patients and in 2 of 39 (5.1%) control children. The latter difference is not significant and suggests that RAP is only rarely caused in children by H. pylori infection.

Abnormal small bowel permeability and duodenitis in recurrent abdominal pain

Thirty nine children with recurrent abdominal pain aged between 5.5 and 12 years, underwent endoscopic duodenal biopsy to find out if there were any duodenal inflammatory changes, and if there was a relationship between duodenal inflammation and intestinal permeability to 51Cr-EDTA. Duodenal inflammation was graded by the duodenitis scale of Whitehead et al (grade 0, 1, 2, and 3). In 13 out of 39 patients (33%) definite signs of inflammation were found (grade 2 and 3). Intestinal permeability to 51Cr-EDTA in patients with duodenitis (grade 1, 2, and 3) was significantly higher (4.42 (1.73)%) than in patients with normal (grade 0) duodenal biopsy appearances (3.3 (0.9)%). A significant association was found between duodenal inflammation and abnormal intestinal permeability. Our results give further evidence that there is an intestinal origin of these patients' complaints.

Small bowel permeability to 51Cr-EDTA in children with recurrent abdominal pain

Small bowel permeability was investigated in 87 children with recurrent abdominal pain by measuring the 24-h urinary excretion of orally administered 51Cr-EDTA. The mean excretion was 3.64% +/- 1.49% per 24 h. The difference between the mean urinary excretion in children with recurrent abdominal pain and control children (2.51% +/- 0.70%), was significant (p less than 0.01, two sample t-test). The increased small bowel permeability in children with recurrent abdominal pain might indicate an intestinal etiology for the patients' complaints.

Diagnostic value of ultrasound in children with recurrent abdominal pain

In order to investigate the diagnostic value of ultrasound in children with recurrent abdominal pain and to estimate the clinical relevance of rare organic causes of abdominal pain in these patients, we prospectively examined 93 children aged between 5.5 and 12 years by means of abdominal ultrasound. In 3 patients (3.2%) an anatomic abnormality was detected, which could not account for the abdominal pain. We conclude that many organic abnormalities, that could be diagnosed by ultrasound, are clinically irrelevant as a cause of recurrent abdominal pain in children and therefore ultrasound does not significantly contribute to the diagnosis. However, ultrasound can still play a role in the work-up of children with recurrent abdominal pain in avoiding unnecessary radiologic X-ray procedures.

Life events and family history in children with recurrent abdominal pain

Children suffering from recurrent abdominal pain (RAP) were compared with matched controls on measures of illness behaviour, parents' illness behaviour, early parent-child relationships and stressful life events. Relatively, the RAP children stayed away from school more, needed more attention when ill, tended to show more anxiety in various ways, had parents who reported more symptoms, and had suffered a greater number of stressful experiences in the few months before pain onset.

Developmental and psychological factors in children's pain

It is clear that previously we were ill-informed and misinformed about children's pain. Recent investigations have led not only to a burgeoning of understanding of pediatric pain, but also an increase in our ability to appropriately measure and treat children's pain. Both pharmaceutical and nonpharmaceutical treatments have made major strides in the past few years. Even more crucial is the change that has happened in the willingness of health professionals to recognize that children do suffer pain and that aggressive treatment is often indicated. However, careful consideration must be given to physiologic, cognitive, affective, and psychosocial development, both in order to maximize the effectiveness of interventions and to recognize the limits that development may place on any specific approach.

Abnormal gastroduodenal motility in children and adolescents with recurrent functional abdominal pain

To determine whether motor activity of the stomach and proximal small intestine is a factor in recurrent abdominal pain in adolescents, we prospectively investigated eight patients with recurrent abdominal pain and compared them with seven normal adolescents. All patients underwent a detailed examination to exclude other known organic causes of the pain. The gastroduodenal motor activity during fasting was studied with a semiconductor recording probe. The recordings were analyzed for periodicity, duration, and propagation velocity of the activity front of the migrating motor complex. The amplitude of the antral and duodenal contractions was also determined. The patients with recurrent abdominal pain had more frequent migrating motor complexes, but these were shorter in duration and moved more slowly down the intestine (slower propagation velocities). The patients also had high-pressure duodenal contractions that were associated with abdominal pain during the study period. These studies suggest that altered intestinal motility may be the underlying mechanism of recurrent abdominal pain in some children.