Recurrent Abdominal Pain In Children
It doesn’t require much imagination when you are asked to name the commonest complaint related to gastrointestinal tract. Without a doubt it is – abdominal pain.
Abdominal pain can either be acute or chronic and its causes can be numerous. The entity I am discussing is one of chronic nature and although very common, still continues to baffle parents and doctors alike. It’s called ‘Recurrent abdominal pain’ or in short- RAP.
What is RAP?
At least one episode of abdominal pain per month over a period of three months, each severe enough to disrupt daily routine is the diagnostic criterion for RAP. It is not a single illness. There are three distinct patterns of RAP. One where there is only paroxysmal abdominal pain; one where in addition there is dyspepsia (pain with eating, fullness, bloating, nausea, vomiting and heartburn) and another one with bowel disturbances like diarrhea and/or constipation.
Many things can cause recurrent abdominal pain. Out of that one peculiar entity has caught the attention of medical world. Some call it an ‘Irritable Bowel syndrome’ and some ‘Functional bowel disease’ but most prefer to term it simply ‘Functional recurrent abdominal pain’. This is the most common variety of RAP regardless of its pattern.
What is Functional RAP?
Functional RAP is seen typically in the age-group of 5 to 15 years. Almost 10-15% of the children from this age-group suffer from this condition. Girls are more likely sufferers. Almost 1 out of 10 such children miss out significantly on school attendance because of pain. Almost half of such patients improve within 2-6 weeks of diagnosis. Remaining half even experience pain in adulthood or suffer from headaches, backaches and menstrual irregularities.
Why do these pains occur?
The very fact that these recurrent pains are called ‘Functional’ means that there is no underlying disease of any particular organ. This is where it starts getting mysterious. On one hand there is a child who is having abdominal pains severe enough to disrupt his daily activities and on the other hand, there is a diagnosis proclaiming ‘There is no disease.’ So what exactly is going wrong?
Theories and hypotheses. That’s all that what we have got to explain this situation. No one knows the exact cause of this pain. One thing is sure that this abdominal pain is for real and not as a result of imitation of adults or to gain undue advantages like parental sympathy or a free holiday from school! Physical and psychological stresses, disturbed motility and sensation of bowels, hormonal factors and autonomic system dysfunction all seem to combine and cause this pain. Genetic predisposition is a strong possibility as many family members of sufferers also have frequent complaints of pain. A family history of irritable bowel disease, peptic ulcer or migraine is common in such patients. Personality and emotional status also affect this occurrence of pain. But there is no evidence to suggest a previously popular theory that such patients are either over-achievers, poor mixers, perfectionists or constant worriers.
How does RAP present?
When RAP presents as an isolated symptom, it is usually a vague pain around the umbilicus. In most patients it lasts for around 1-3 hours with pain-free periods in between. There is no relation to food, activity or bowel habits and usually this pain doesn’t radiate to other parts. Although often it can cause difficulty to sleep at night for the patient, almost never does it cause him to wake up from sleep. The patient might double up wincing and clutching his abdomen. Nausea, dizziness, headache, pallor, excessive sweating and slightly raised temperature (99-100*F) are often present along with.
What are the necessary investigations?
In such cases it is necessary to recognise the possibility of Functional RAP and not go overboard with excessive tests and investigations. Such panicky response would only cause more stress to parents and patient and in fact worsen the pain episodes. So when the clinical pattern, age-group and age of onset are fitting and when the physical examination is normal, only basic investigations like complete blood count, ESR, urine analysis with culture and a detailed stool examination to rule out occult blood and parasites are needed. More often than not, a good case history, a thorough physical examination and these few investigations are enough to rule out any serious internal disease. RAP with dyspepsia and RAP with diarrhea and/or constipation require more detailed work-up but even there too, the functional variety is the most likely cause.
What are the danger signals?
The danger signals which alert us to the possibility of any serious cause of abdominal pain are pain awakening the child from sleep, location of pain away from umbilicus, weight loss, growth deceleration, sleepiness following attacks, associated symptoms (like fever, rash or joint pains), blood in stools, anemia, elevated ESR and a positive family history of peptic ulcer or inflammatory bowel disease. In presence of any of these, a more detailed investigative work-up is necessary to get to the root of the cause.
What is the treatment?
The first and foremost part of treatment is demystification of this situation. Parents and child both should be explained in simple words that though the pain is real, it is self-limiting and not dangerous.
The next part of management is modification of environment. The stressful stimuli which precipitate such painful episodes should be identified and removed if possible. Parents and even school authorities should be encouraged to promote normal activity as far as possible even during pain-episodes instead of indulging in over-protective, anxious behaviour.
Diet needs some adjustments. High fiber diets don’t improve the pain and in fact might worsen pain. Avoidance of excess lactose (milk products), fructose (carbonated beverages), starches (potatoes, corn, wheat, oats) and sorbitol (gums and candies) might offer some relief.
Medicines like anti-spasmodics, anti-cholinergics and anti-convulsants are not needed on a long term basis. Local massage and warmth, a short term treatment with anti-spasmodics and reassurance about transient nature seems to be the best treatment for such pain.
So in summary,
1. Functional recurrent abdominal pain is the commonest cause of abdominal pain in the age-group of 5-15 years.
2. It is not dangerous and is mostly self-limiting.
3. Reducing stress, encouraging normal activity, slightly modifying the diet and occasional anti-spasmodic- administration usually suffice as treatment.
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Right Parenting.Com is a site dedicated to offer compassionate scientific guidance on various parenting and child-health issues. It is managed by Dr. Mandar V. Bichu, a Sharjah-based paediatrician with the help of experts in various fields.
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