# Frequent stomachaches in children: a reason for concern?



## eric (Jul 8, 1999)

FYI with permissionFrequent stomachaches inchildren: a reason for concern?By Miranda Van Tilburg, PhDAssistant Professor of MedicineDivision of Gastroenterology andHepatologySchool of MedicineThe University of North Carolina atChapel HillMost children will complain ofa stomachache once in a while,because it is one of the most commonchildhood pain experiences.Complaints can range from a vaguequeasy feeling in the stomach todoubling over in pain accompaniedby vomiting, diarrhea or constipation.Fortunately, in a majority of cases,the reasons for a stomachache are minor andrelatively benign. Most often, the complaintsettles without a specific diagnosis, even whena doctor is consulted.However, some children are more prone todeveloping abdominal pain than others. Thesechildren experience frequent stomachachesover a period of several months to several years,which can be very disrupting in the childâ€™s life.Due to (a fear of developing) stomachaches,these children often miss out on family events,social outings with friends, and attending school.Stepping out of normal life in this way makesthese children vulnerable to loneliness, anxiety,depression and low self-esteem.In the late 1950â€™s, the English pediatrician JohnApley was one of the first to systematically studyand describe this phenomenon of childhoodstomachaches, which he named RecurrentAbdominal Pain (RAP). In his first monologue onRAP, Apley describes the typical situation of achild who complains of frequent stomachaches.This child has been sent home from schooland may even have vomited however, by thetime he arrives at the doctorâ€™s office, the painis usually gone and upon examination nothingbut indefinite tenderness in the abdomen isfound. The doctor usually does not find anythingdefinitive on which to base a diagnosis. Mostlikely, the child has had the stomach pain before as well as somebody in his immediate family. Thepediatrician feels he or she can wait for furtherdevelopments with the child but has doubtsabout having missed something. Was (s)he rightto express only reassurances or should furtherinvestigations have been carried out? Thisdescription of the pain-prone familyand doubtful physician is still truetoday.What is RAP?Apley defined RAP as at least threeepisodes of pain occurring withinthree months that are severe enoughto affect the childâ€™s activities. Thisdiagnosis is still widely used inclinical practice and research.Sometimes, Rome classificationis used, with the most commondiagnoses being FunctionalDyspepsia (FD) or Irritable BowelSyndrome (IBS). FD is diagnosed when therehas been at least 12 weeks of persistent orrecurrent pain in the upper abdomen, withoutevidence of organic disease and no relief withdefecation or change in stool form or frequency.IBS is diagnosed when there has been at least 12weeks of abdominal pain, without structural ormetabolic abnormalities and at least two of thefollowing three features -- relief with defecation,change in stool frequency, or change in stoolconsistency. Upon careful review of RAP patients,it is found that pediatric IBS is very common â€“ 45to 70% of RAP patients meet Rome criteria forIBS and about 16% are ascertained to suffer fromfunctional dyspepsia.Nobody is in as much pain as my childRAP patients and their parents often believe theirsymptoms are unlike â€œnormalâ€ stomachachesreported by other children. Pediatricians andgastroenterologists, on the other hand, perceiveRAP as a problem that is overflowing theirpractices. The truth lies somewhere in betweenthese two perspectives. RAP is one of the mostcommon chronic pain complaints in childhood,but only 10 to 25% of children are affected.Symptoms often wane with time and spontaneousremission of RAP is likely. Yet, more than halfof RAP children will continue to suffer fromfrequent somatic or psychological symptomsinto adulthood. For example, Christensen andMortensen reported that 11 out of the 18 RAPpatients in their study suffered from abdominalpain 29 years later.Frequent stomachaches in children: a reason for concern?Miranda Van Tilburg3out as early as possible. Depending on the symptoms, aphysician can order blood, urine and stool tests to ruleout some common conditions. But, the use of X-rays, CTscansand endoscopies are usually restricted to cases inwhich the history or physical exam raises questions as tothe diagnosis. Even with extensive testing, the odds areagainst finding an organic cause for a child who meetssymptom criteria for RAP. In only one out of 10 cases,an organic cause can be identified and misdiagnosisis extremely rare. Even up to 20 years after an initialdiagnosis of RAP, the chance of identifying an initiallyundiagnosed organic disorder is very low.Is it all in your head?Apley believed that if there is no organic cause for thepain, then the stomachaches are psychogenic. In otherwords, RAP patients suffer from an emotional disorder.He came to this conclusion because stress seemed toexaggerate or precede pain attacks and psychotherapywas usually effective in relieving attacks. In trying toexplain the absence of abnormal physiological findings,many have followed Apleyâ€™s lead and suggested thesechildren suffer from psychological problems. RAPpatients have been described as fussy, perfectionistic,high strung and anxious, and several studies haveshown they suffer from more psychological problemsthan healthy children.However, the landmark work of Walker & Greenehas shown that anxiousness is a consequence of thepresence of abdominal pain rather than a cause. RAPpatients are not necessarily more anxious or depressedthan patients suffering from peptic ulcer or IBD, in whichthe abdominal pain is caused by inflammation of the GItract. These findings suggest that chronic abdominal painaffects patients in similar ways regardless of etiology,and the notion that RAP is a psychogenic disorder hasnow fallen largely out of favor. Psychosocial factors areassumed to influence GI functioning and can exaggeratesymptoms, but they play only a limited causal role.Suffering from abdominal pain does, however, generatepsychological distress. It can produce not only anxietybut also increased depressive symptoms, somatizationand lower self-esteem. Now it is understood that thecause of RAP is neither organic nor psychogenic,but there is close interplay between physiology andpsychology.What is causing RAP?Although no structural abnormalities or diseasesmay be found, RAP patients do show some abnormalphysiological characteristics. There is growing evidencethat a disruption in the functioning of the GI tract is oneof the major causes of RAP. This basically means that theFrequent stomachaches in children: a reason for concern?In other words, RAP patients sufferfrom an emotional disorder. He cameto this conclusion because stressseemed to exaggerate or precedepain attacks and psychotherapy wasusually effective in relieving attacks.Are RAP stomachaches real, imagined or faked?Since stomachaches are notoriously used as an excusefor skipping school, they have gotten a bad reputation.A child with RAP is often thought of as a whiner whouses his bellyaches to get attention or get out of things,especially when a physiological cause for the paincannot be identified. RAP children and their familiesface this type of prejudice almost daily, even amongmany health care professionals. However, it is importantto understand that the pain of RAP is real and not fakedor imagined. Even abdominal pain caused by stressor worry about going to school is usually real. Mostchildren never think about faking it. Acknowledging thevalidity of RAP stomachaches is the right thing to do,but keeping a child who suffers from RAP out of schoolevery time he or she complains is not necessary. If noother symptom, such as vomiting or fever is present, itis usually safe for the child to go to school.Has a serious disease been overlooked?Both parents and physicians are often doubtful aboutthe diagnosis of RAP. There is no marker or test toidentify RAP; the diagnosis is made purely on the basisof symptom characteristics. Common organic causes ofabdominal pain are usually ruled out before giving adiagnosis of RAP. The list of disorders that can causeabdominal pain is lengthy and, generally, it is neitherethically nor financially possible to test every child forall possibilities. Serious illnesses can sometimes explainrecurrent stomachaches and it is important to rule theseWhen RAP persists into adulthood, these patientsare most likely to develop IBS. There are strikingsimilarities between adulthood IBS and childhood RAPin terms of prevalence, course, medical and psychiatricco-morbidity, family medical and psychiatric history,and stressful life events. There is data to suggest thatthe prognosis is worse for children who have a parentwho suffers from recurrent pain and for children whoexperience more negative life events. Therefore,although it is true that some children will eventuallygrow out of their stomachaches, there is a good chancethat abdominal or other somatic symptoms will reoccurlater in life.4bodies of children with RAP work somewhat differently.This etiological model has been adapted largely fromresearch findings on adulthood IBS. As discussed earlier,childhood RAP has many similarities with adulthoodIBS and many young RAP patients will have or developabdominal pain in their adult life. RAP is therefore oftenseen as a precursor to adulthood IBS and identicaletiological mechanisms have been suggested. It isimportant to realize, however, that few studies to datehave focused on etiological mechanisms of childhoodRAP compared to the extensive literature on adult IBS,and findings have not always been identical.It has been suggested that the Autonomic NervousSystem (ANS) is disrupted in RAP. The ANS consists ofneurons that run between the central nervous system(e.g., the brain) and various internal organs, such asthe bowels and stomach. The ANS is responsible formonitoring conditions in the internal environmentand bringing about appropriate changes in them.For example, after eating, the ANS acts to ensure thestomach and bowel contract to move the food throughthe digestive tract. This happens largely involuntary,although we do have some control over our bowels asis shown by people practicing yoga or under hypnosis.It has been suggested that the ANS in RAP is weak -- itdoes not adapt to changes as effectively as in healthychildren. For example, after stimulation of the rectum,RAP patients show slower recovery than children whodo not suffer from RAP.A second mechanism that could explain RAP isdisruptions in motility (the speed with which foodmoves through the digestive system). In many cases,RAP is associated with either diarrhea or constipation.This seems to suggest that food is either moving tooquickly or too slowly through the bowels and that thismotility problem could account for the pain. Somestudies have observed increased transit time in RAPpatients, but these findings have not been found in allstudies. Furthermore, adding fiber to the diet to slowtransit time has been found to benefit only a subgroupof RAP patients.Lately, visceral hypersensitivity has receivedconsiderable attention as one of the major pathways thatcauses RAP symptoms. Visceral hypersensitivity meansthat nerves in the gut are very sensitive: RAP patientsfeel pain in areas of the GI tract much more easily.Because of this heightened sensitivity, RAP childrenperceive â€˜normalâ€™ gastrointestinal events -- such assmall increases in motility or gas -- as painful.There is convincing evidence of visceral hypersensitivityin many adult IBS patients and it has been reported inchildren with RAP, as well. This abnormal perception ofpain (low pain threshold) can be due to changes in boththe central (brain) and enteric (gut) nervous system.Nerves in the gut can become overly sensitive and startreacting to events that would otherwise be ignored. Thebrain, on the other hand, can overreact by not inhibitingas much information coming from the gut as usual,thereby enabling more pain stimuli to pass throughinto our awareness. Psychological distress can augmentthese processes.It should be emphasized that there might be differentetiologies explaining RAP. In some children abdominalpain might be caused by disruptions in the ANS, whilefor others the pain is due to an increase in motility orvisceral hypersensitivity, and for a third group the painmay be largely psychogenic. It is very likely that in mostRAP patients multiple mechanisms can be identifiedthat influence each other. For example, frequent severepain due to increased motility may eventually lead tohypersensitivity for motility which, in turn, generatesmore pain due to heightened sensitivity to changes inmotility.What about stress?Many parents, children and physicians understand thatstress can exacerbate the pain. However, most studiesso far have failed to find a clear relationship betweenmajor stressors (such as death or illness in the family, adivorce, or a move) and the occurrence of RAP. It mightbe possible that minor chronic stresses or daily hassles-- such as having to wait in line at the store, quarrelswith siblings, constantly stopping for bathroom visits,or vigilantly monitoring what oneâ€™s eating -- may befar more significant than the stress of major life events.Unfortunately, there is still little research on the effectsof minor chronic stress.Effectiveness in coping may be even more important inexplaining RAP than exposure to stress. When a child isan effective coper, even high levels of stress might notaffect him or her very much. By contrast, an ineffectivecoper is likely to become distressed when faced withonly minor setbacks in life. Coping with abdominalpain and other stresses is often difficult for childrenwho suffer from RAP. Many RAP children use avoidancestrategies such as denial, avoiding thinking about it andwishful thinking which, in turn, can result in elevatedlevels of pain, somatic symptoms and distress. Bycontrast, effectively adapting to (coping with) the painby regulating attention and cognitions (e.g., distraction,acceptance of the pain or positive thinking) areassociated with less pain, fewer somatic symptoms andFrequent stomachaches in children: a reason for concern? 5less distress. Acting directly on the pain in an attempt tochange the environment or oneâ€™s emotions (e.g., takingmedications, visiting a physician, reducing stress inoneâ€™s life) can be somewhat helpful, but these actionsdo not appear to influence the pain very much.Are non-GI symptoms related to RAP?Children with RAP can present with a multitude ofother unexplained symptoms (co-morbidity), andthe physician may wonder if these are related to thestomachaches. Co-morbid symptoms are importantsince they may be indicative of: (1) psychologicalproblems that could either drive the GI symptoms orbe a consequence of coping with multiple pains, or(2) more severe or longer duration of pain which cantrigger pain in other areas. Relatively little is knownabout co-morbid somatic symptoms in RAP. Abouthalf the children who report stomach pain indicatemore than one pain location. Multiple pain sites aremore commonly reported by girls than boys, and theyincrease with age. The most common combination isheadache and abdominal pain and is reported in 25%of cases with two sites of chronic pain.In a study of RAP patients consulting a physician, thenumber of co-morbid symptoms was found to increasewith the duration of RAP. In other words, one pain mightinitiate other pain. But, it could also be possible thatonly those patients who have multiple symptoms areseen by a doctor over a longer period of time. Anotherstudy did not find a relationship between the durationof stomachaches and the occurrence of other symptomsduring a three-month follow-up of patients. However,three months might have been too short a period oftime to see an effect. More research into associatedsymptoms, who is at increased risk, and what is causingthe co-morbidity is needed.Do more severe symptoms result in moredisability?RAP has a large impact on suffering, health care costsand functional disability. School absences are one ofthe most common and obvious effects of RAP, and oftenone of the first goals in therapy is to resume schoolattendance. The RAP child who misses school also tendsto use more health care services. Health care resourceuse is particularly high among RAP patients, but not allchildren who suffer from RAP consult a doctor or missschool. Currently, there is little research-based insightinto the characteristics of the child who is most likely tomiss school and consult a physician for stomachaches.In a study by Hyams and colleagues, only 9% to10% ofmiddle and high school students with RAP reported theyhad seen a doctor for abdominal pain within the lastyear. But, students who did visit a doctor for abdominalpain reported increased pain severity, frequency andduration and more disruption of their lives. In a studyby Venepalli and colleagues, health care consulting andschool attendance of middle school children could notbe predicted by pain intensity or psychosocial distressof either the mother or the child. Identification of childrenwho show high levels of functional disability is important,because this would allow for targeting (preventive)interventions, determining cost-effectiveness of care,and preventing poor academic performance due toschool absences.Are the parents to blame?Physicians confronted with an anxious parent of a childwith RAP often feel these parents play a major role inthe maintenance and exacerbation of the symptoms.Parents for RAP children, on the other hand, feel theyhave no control over the situation and do not appreciatebeing â€˜blamedâ€™ for their childâ€™s symptoms. It is importantto understand that a disorder seldom affects only thepatient. People around the person in pain are affected,as well -- they can be stressed about the pain and itsmeaning. In fact, many parents of children who sufferfrom abdominal pain show increased levels of anxietyand somatization themselves. This is a normal reactionand does not imply that parents cause RAP.However, parental beliefs, stress, and coping strategiesare of great influence on the childâ€™s pain perceptionof pain. Children are still developing their copingrepertoires and look to adults for guidance aboutwhen to get anxious or worried and how to deal withsymptoms. When a child is sick, in pain or discomfort,parents have the difficult task of interpreting theseriousness of the symptoms and deciding how to takeaction. Any parental action or reaction will influencehow their children approach future illness and health.How can a doctor help a child who suffers fromRAP?Standard medical care for RAP consists of (1) limitedmedical tests to rule out organic diseases, (2)acknowledgment that the pain is real, (3) reassurancethat there is no illness causing the pain, and (4) adviceon how to cope with the symptoms. Parents and childrenneed to be partners with their physician in their healthand health care. Since most patients visit a physician insearch of a â€˜cure,â€™ it is important for physicians to explainthat RAP is a chronic condition and that returning tonormal life as much as possible is the goal, rather thancomplete pain relief. Medications can be given to treataccompanying symptoms, such as constipation.6 Frequent stomachaches in children: a reason for concern?Many RAP patients may come to the doctorâ€™s office withquestions about diet. In fact, most of them will havechanged their eating behavior before seeing a doctor.They may propose that food sensitivities, unhealthydiets or dysfunctional eating patterns are possiblecauses of the symptoms. At this time, there is onlylimited data on the effects of diet on RAP symptoms.The most extensively studied are the influence oflactose malabsorption and lack of sufficient fiber in thediet. Many parents will have placed their children ona lactose-free diet, but the majority of patients do notreport benefits from this dietary restriction. Even lactoseintolerantchildren do not necessarily see a significantimprovement in their RAP symptoms, suggesting thatlactose intolerance might be an additional dysfunctionthe child is dealing with but it is not a major cause forthe stomachaches. As mentioned above, fiber therapycan be helpful in some cases, but the currently limitedresearch data is conflicting with regard to its benefit.Nevertheless, some suggest that because of its low costand low risk, it might be worthwhile to try high fibertherapy in children presenting with RAP.Although standard medical care can result in significantimprovements, many RAP patients need additionaltherapy. Psychological therapies such as CognitiveBehavioral Therapy (CBT) have been found to beeffective in treating RAP. CBT teaches children and/ortheir parents to change unhelpful thoughts about thedisorder and learn effective coping skills, and it is oftencombined with relaxation exercises. CBT has been shownto produce significant improvements in pain, health careutilization and school attendance. Unfortunately, thesetherapies are not available to a majority of the RAPpatients. They require multiple meetings with a highlytrained therapist, insurance often does not necessarilycover these costs, and most physician offices lack thetime and resources to implement such a program. Thereis a need for effective psychological treatments for RAPthat are more accessible.There is no quick fix for RAP and the road to recovery canbe bumpy and challenging for all parties. Patients andtheir families may feel misunderstood and discouragedby relapses. Physicians might feel they are not able toconvey their message to the family or lack the time togive adequate coping advice. Although RAP is a verychallenging disorder, there are many ways in whichchildren, their parents and physicians can help to easethe pain. No one approach will work in every child, butthe right combination of understanding the disorderand its causes, medications, reduction of stress, changesin eating and bowel movement patterns, coping advice,and encouragement to fully participate in school andsocial life can be of great benefit in managing, reducingand controlling the pain. For many children, the care andencouragement of a good physician will be sufficient totake control over the symptoms.However, for children needing additional care, it canbe challenging to find the right therapist or therapies.This gap is recognized and more research is beingdone in developing behavioral interventions. Forexample, the UNC Center for Functional GI & MotilityDisorders is currently partnering with Dr. Rona Levy atthe University of Washington to test a short CognitiveBehavioral Therapy for RAP in which both the childrenand parents are involved. At UNC, we are also in theprocess of developing a hypnosis program for RAP thatcan be used by any health care professionals withoutextensive training, making it more widely available tomany patients. Some pediatric gastroenterologists arealready teaming up with therapists who have specializedin pediatric GI disorders.In sum, the most important intervention for childrenwho suffer from recurrent abdominal pain is to reassurethem that we understand their pain is real but also that itcan be managed with appropriate medical care and/orpsychological therapy.Selected reading (a complete reference list can be obtained from theauthor)Apley J, Naish N. Recurrent abdominal pain: A field study of 1000school children with recurrent abdominal pain. Archives of Diseasesof Childhood 1958;46:337-340.Scharff L. Recurrent abdominal pain in children: a review ofpsychological factors and treatment. Clin Psychol Rev 1997;17:145-166.Christensen MF, Mortensen O. Long-term prognosis in children withrecurrent abdominal pain. Arch Dis Child 1975;50:110-114.Hyams JS, Burke G, Davis PM, Rzepski B, Andrulonis PA. Abdominalpain and irritable bowel syndrome in adolescents: a communitybasedstudy. J Pediatr 1996;129:220-226.Venepalli N, Van Tilburg MAL, Whitehead WE. Recurrent AbdominalPain (RAP): The relationship between illness behaviors and healthservices consulting? American Journal of Gastroenterology2004;126:A372.Walker LS, Greene JW. Children with recurrent abdominal pain andtheir parents: More somatic complaints, anxiety, and depression thanother families? Journal of Pediatric Psychology 1989;14:231-243.Walker LS, Garber J, Greeene JW. Psychosocial correlates of recurrentchildhood pain: A comparison of pediatric patients with RecurrentAbdominal Pain, organic illness and psychiatric disorders. Journalof Abnormal Psychology 1993;102:248-258.Walker LS, Claar RL, Garber J. Social consequences of childrenâ€™spain: when do they encourage symptom maintenance? J PediatrPsychol 2002;27:689-698.â€¢7 Frequent stomachaches in children: a reason for concern?


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