• Information
  1. Definition
  2. Epidemiology
  3. Etiology
  4. History
  5. Typical Symptoms
  6. Concerning
  7. Concerning
  8. Laboratory Studies
  9. Treatment
  10. Prognosis

A. Definition

1. Occurs at least once a month
2. Lasts at least 3 months
3. Interferes with functioning at home, school or in peer relationship

B. Epidemiology

1. Affects 10-15% of children
2. Most common chronic pain syndrome in children
3. Presents in middle childhood
4. Female to male ratio 5:3

C. Etiology

1. Etiology is almost never organic (5% of cases only)
2. Common organic diagnoses
   1. H. pylori gastritis
   2. Irritable Bowel Syndrome
   3. Carbohydrate Intolerance
   4. Peptic Ulcer Disease
3. Constipation
4. Enteric duplication cyst (very uncommon) [7]

D. History

1. Ask patient to describe first, last and most severe episode of pain
2. The first and most severe episode will be the most pathologic and may form the pattern for other episodes
3. Determine overall functioning of child and family
4. Response of care givers to pain

E. Typical Symptoms

1. 2-3 episodes a week for several weeks but then absent for several months
2. Typically sudden onset of generalized or peri-umbilical pain
3. Duration of symptoms usually less than 1 hour
4. Associated with autonomic symptoms (pallor, sweating, nausea, vomiting, and palpitation)
5. No temporal relationship to activity, meals or bowel habits

F. Concerning ("Red Flag") Symptoms

1. Systemic or constitutional symptoms
2. Changes in bowel habits
3. Vomiting
4. Nighttime awakening
5. Dysuria
6. Joint involvement
7. Constant or prolonged pain
8. Rectal bleeding

G. Concerning ("Red Flag") Physical Findings

1. Weight loss
2. Organomegally
3. Anal fissures or peri-rectal ulcerations
4. Occult blood in stool
5. Joint swelling or pain
6. Associated rash

H. Laboratory Studies

1. Routine Screening
   1. Complete blood count (CBC)
   2. ESR
   3. Urinalysis and urine culture (patients)
   4. Stool occult blood
2. Other tests to consider
   1. Giardia antibody
   2. Ova and parasites (usually three separate tests)
   3. Abdominal radiograph
   4. Lactose Breath Test
   5. H. pylori titers
   6. Abdominal ultrasound

I. Treatment

1. Demystification
   1. Reassurance
   2. Identify as common clinical entity
   3. Have parents speak to other parents of similar age children
   4. Address the fears and concerns of child and parent
2. Behavioral management
   1. Have child rest until pain resolves
   2. Retain normal routine as much as possible
   3. Require office visit for missed days of school due to abdominal pain
   4. Praise child's coping skills
3. Symptom Diary
   1. Note timing of events
   2. Record patient's description of episode
   3. Use the record to identify triggers and pain patterns
4. Dietary and other Interventions
   1. Trial off dairy products, including soy milk (instead of Cow's Milk) [6]
   2. Consider confirming with lactose breath test
   3. Avoid sorbitol or fructose
   4. High fiber diet
   5. Avoid analgesic use to prevent emphasis on the medical model
5. Psychosocial support
   1. Involve other care providers
   2. Communicate directly with school or day care personal
   3. Psychiatric consult only needed for conversion reactions, extreme episodes or maladaptive coping mechanisms
   4. Formulate a coordinated management plan

J. Prognosis

1. One third of cases resolve spontaneously
2. One third continue to have recurrent abdominal pain
3. One third develop other pain syndromes in adolescence or adulthood
   1. Irritable bowel
   2. Migraine headache

References

1. Boyle JT. 1997. Pediat Rev. 18(9)310
2. Hyams JS. 1997. Current Opin Pediat. 7:525
3. Drossman DA. 1996. Am J of Gastroenterol. 91(11)2270
4. Frazer CH and Rappaport LA. 1996. Ambulat Child Health. 1:370
5. Oberlander TF and Rappaport LA. 1993. Pediat Rev. 14 (8)313
6. Iacono G, Cavataio F, Montalto G, et al. 1998. NEJM. 339(16):1100
7. Curci MR and Compton CC. 2000. NEJM. 342(11):801