Incidence of non-specific abdominal pain in children during school term: population survey based on discharge diagnoses

The predictive value of childhood recurrent abdominal pain for adult emotional disorders, and the influence of negative cognitive style. Findings from a cohort study

Background

Recurrent abdominal pain (RAP) in childhood is common, with no explanatory pathology identified in the majority of cases. Previous studies have consistently demonstrated an association between childhood RAP and later emotional distress disorders. The aim of this study was to replicate this finding through the analysis of a large dataset, and explore how a negative style of thinking could potentially influence this relationship.

Methods

The Avon Longitudinal Study of Parents and Children (ALSPAC) is a population cohort of children born in the Avon area of the UK, between 1991–1992. Data on childhood RAP was collected via maternal reports at 3, 4, 7 and 9 years. Mood, anxiety and cognitive style were measured at age 18. We controlled for various confounding factors, including maternal anxiety and the child’s pre-existing psychopathology. Logistic regression models were used to examine associations, and moderation effects of cognitive style were analysed using likelihood ratios.

Results

Experiencing RAP at any one time-point is associated with an increased odds of depression and/or anxiety disorder at 18 (OR = 1.41, 95% CI 1.09–1.83). We found a dose-response relationship and each additional marker of RAP was associated with a 26% (CI: 7% to 47%) increase in risk of having a mood and/or anxiety disorder. Individuals who attribute adversity to global, stable or personal factors were at amplified risk.

Conclusions

Childhood RAP predicts depression and anxiety disorders at 18 and should be targeted for early intervention. Individuals with a negative cognitive style may be particularly vulnerable, suggesting that cognitive interpretations of physical symptoms could play an important role in long-term health outcomes.

Practical management of functional abdominal pain in children

Functional abdominal pain (FAP) is common in childhood, but is not often caused by disease. It is often the impact of the pain rather than the pain itself that results in referral to the clinician. In this review, we will summarise the currently available evidence and discuss the functional dimensions of the presentation, within the framework of commonly expressed parental questions. Using the Rome III criteria, we discuss how to classify the functional symptoms, investigate appropriately, provide reassurance regarding parental worries of chronic disease. We outline how to explain the functional symptoms to parents and an individualised strategy to help restore function.

Diagnostic outcomes following childhood non-specific abdominal pain: a record-linkage study

AIMS

Non-specific abdominal pain (NSAP) is the most common diagnosis on discharge following admission for abdominal pain in childhood. Our aim was to determine the risk of subsequent hospital diagnosis of organic and functional gastroenterological conditions following a diagnosis of NSAP, and to assess the persistence of this risk.

METHODS

An NSAP cohort of 268,623 children aged 0-16 years was constructed from linked English Hospital Episode Statistics from 1999 to 2011. The control cohort (1,684,923 children, 0-16 years old) comprised children hospitalised with unrelated conditions. Clinically relevant outcomes were selected and standardised rate ratios were calculated.

RESULTS

From the NSAP cohort, 15,515 (5.8%) were later hospitalised with bowel pathology and 13,301 (5%) with a specific functional disorder. Notably, there was a 4.84 (95% CI 4.45 to 5.27) times greater risk of Crohn's disease following NSAP and a 4.23 (4.13 to 4.33) greater risk of acute appendicitis than in the control cohort. The risk of irritable bowel syndrome (IBS) was 7.22 (6.65 to 7.85) times greater following NSAP. The risks of inflammatory bowel disease (IBD), IBS and functional disorder (unspecified) were significantly increased in all age groups except <2-year-olds. The risk of underlying bowel pathology remained raised up to 10 years after first diagnosis with NSAP.

CONCLUSIONS

Only a small proportion of those with NSAP go on to be hospitalised with underlying bowel pathology. However, their risk is increased even at 10 years after the first hospital admission with NSAP. Diagnostic strategies need to be assessed and refined and active surveillance employed for children with NSAP.

Do headache and abdominal pain in childhood predict suicides and severe suicide attempts? Finnish nationwide 1981 birth cohort study

This study investigated associations between pain symptoms in mid-childhood and severe suicidality in adolescence and early adulthood. Severe suicidality was defined as completed suicide or suicidal attempt requiring hospital admission. In a nationwide prospective population-based study (n = 6,017), parents and children were asked about the child's headache and abdominal pain at age eight. The outcome was register-based data on suicide or suicidal attempt requiring hospital treatment by age 24. Family composition, parental educational level, and the child's psychiatric symptoms reported by the child, parents and teacher at baseline were included as covariates in statistical analyses. Boys' abdominal pain reported by the parents was associated with later severe suicidality after adjusting for family composition, parental educational level, and childhood psychiatric symptoms at baseline. In addition, the association between boys' own report of headache and later severe suicidality reached borderline significance in unadjusted analysis. Girls' pain symptoms did not predict later severe suicidality.

The course of mental health problems in children presenting with abdominal pain in general practice

OBJECTIVE

To investigate the course of mental health problems in children presenting to general practice with abdominal pain and to evaluate the extent to which abdominal pain characteristics during follow-up predict the presence of mental health problems at 12 months' follow-up.

DESIGN

A prospective cohort study with one-year follow-up.

SETTING

53 general practices in the Netherlands, between May 2004 and March 2006.

SUBJECTS

281 children aged 4-17 years.

MAIN OUTCOME MEASURES

The presence of a depressive problem, an anxiety problem, and multiple non-specific somatic symptoms at follow-up and odds ratios of duration, frequency, and severity of abdominal pain with these mental health problems at follow-up.

RESULTS

A depressive problem persisted in 24/74 children (32.9%; 95% CI 22.3-44.9%), an anxiety problem in 13/43 (30.2%; 95% CI 17.2-46.1%) and the presence of multiple non-specific somatic symptoms in 75/170 children (44.1%; 95% CI 36.7-51.6%). None of the abdominal pain characteristics predicted a depressive or an anxiety problem at 12 months' follow-up. More moments of moderate to severe abdominal pain predicted the presence of multiple non-specific somatic symptoms at follow-up.

CONCLUSIONS

In one-third of the children presenting to general practice for abdominal pain, anxiety and depressive problems persist during one year of follow-up. Characteristics of the abdominal pain during the follow-up period do not predict anxiety or depressive problems after one-year follow-up. We recommend following over time children seen in primary care with abdominal pain.

Psychosocial determinants of headache, abdominal pain, and sleep problems in a community sample of Finnish adolescents

The aims of this study were to examine the prevalence, co-occurrence, and psychosocial determinants of self-perceived headache, abdominal pain, and sleep problems among adolescents. The adolescents from two cities in Finland (n = 2,215, 90.9% of the target population) attending 7th and 9th grade (age range 13-18 years) participated in the cross-sectional survey inquiring about frequency of headache, abdominal pain, sleep problems, and psychosocial difficulties. The 6-month prevalence of weekly headache was 13%, abdominal pain 6%, and sleep problems 27%. All three symptoms were strongly associated with each other. Of the adolescents suffering from one symptom, 32% reported one co-occurring symptom and 17% two co-occurring symptoms. In the multivariate analysis, female gender, experience of psychological difficulties, emotional symptoms, smoking, victimization, and feeling not cared about by teachers were independently associated with all the individual symptoms, as well as an increasing number of symptoms. Sleep problems were associated with older age and peer and alcohol problems. Abdominal pain was associated with conduct problems, and both headache and abdominal pain were linked with immigration background. An increasing number of symptoms was associated with older age, having a chronic illness, and conduct and alcohol problems. Adolescents' headache, abdominal pain and sleep problems were common and often co-occurred. An increasing frequency of each symptom and number of symptoms were associated with psychosocial factors in a similar way. Screening for psychiatric symptoms, substance use, victimization and difficulties with teachers should be included in the assessment of adolescents who suffer from recurrent headache, abdominal pain or sleep problems.

Unspecified abdominal pain in primary care: the role of gastrointestinal morbidity

BACKGROUND

Many patients with abdominal pain have no obvious cause for their symptoms and receive a diagnosis of unspecified abdominal pain.

AIM

The objective of this study was to ascertain risk factors and consequences of a diagnosis of unspecified abdominal pain in primary care.

METHODS

A population-based, case-control study was conducted using the UK General Practice Research Database. We identified 29,299 patients with a new diagnosis of abdominal pain, and 30,000 age- and sex-matched controls. Only diagnostic codes that did not specify the type or location of abdominal pain were included.

RESULTS AND DISCUSSION

The incidence of newly diagnosed unspecified abdominal pain was 22.3 per 1000 person-years. The incidence was higher in females than in males, and 29% of patients were below 20 years of age. Prior gastrointestinal morbidity was associated with abdominal pain, but high body mass index, smoking and alcohol intake were not. Patients newly diagnosed with abdominal pain were 16 to 27 times more likely than controls to receive a subsequent new diagnosis of gallbladder disease, diverticular disease, pancreatitis or appendicitis in the year after the diagnosis of abdominal pain. The likelihood of receiving other gastrointestinal diagnoses such as peptic ulcer disease, hiatus hernia, gastro-oesophageal reflux disease (GERD), irritable bowel syndrome (IBS) or dyspepsia was increased three- to 14-fold among patients consulting for abdominal pain.

CONCLUSION

When managing abdominal pain in primary care, morbidities such as GERD and IBS should be considered as diagnoses once potentially life-threatening problems have been excluded.

The impact of recurrent abdominal pain: predictors of outcome in a large population cohort

AIM

Recurrent abdominal pain is one of the commonest complaints of childhood, affecting approximately 10% of children at any one time. This study aims to describe the outcome of recurrent abdominal pain amongst 6-year-old children, and to identify risk factors (in both the children and their parents), which predict these outcomes.

METHODS

7128 6-year-old children in the Avon Longitudinal Study of Parents and Children (ALSPAC) were followed up for 1 year. The principle outcomes were abdominal pain, number of days missed from school in the preceding year and psychiatric diagnoses.

RESULTS

Children with recurrent abdominal pain at age 6 years had higher rates of further abdominal pain [odds ratio 4.88 (95% CI: 4.01, 5.95)], school absence (10 or more days off school in a year) [OR 1.89 (1.53, 2.33)] and anxiety disorders [OR 2.36 (1.68, 3.32)] at age 7 years. Maternal anxiety was the most consistent predictor of subsequent adverse outcomes for these children.

CONCLUSION

Children with recurrent abdominal pain are at significant and continuing risk of adverse functioning. It is important for clinicians to take a whole family perspective, and particularly to consider parental anxiety, when a child with recurrent abdominal pain presents to them.