# Children and ibs



## eric (Jul 8, 1999)

FYIHow Doctors Help Children Tame the Beast in the BellyNY Times October 5, 2004 LAURIE TARKANWhen 12-year-old Hannah Scott began middle school last year, she was so nervous that her stomach was not just in knots, it was in serious pain. "It would start in the morning when I'd leave the house," said Hannah, a thin wisp of a girl with light brown freckles and long sandy hair. "And when I got to school, it was really, really bad. I'd go to the nurse every other day, and be sent home." When the bellyaches persisted for months, Hannah's parents took her to a pediatric gastroenterologist, who ordered tests, including X-rays, a colonoscopy and an endoscopy, to rule out serious problems. After nothing showed up, the ailment was diagnosed as irritable bowel syndrome, a gastrointestinal disorder with no organic cause and no proven treatment in children. But the doctor said there was nothing to do about it; eventually, it got so bad that her parents pulled her out of school. An estimated 10 to 20 percent of all school-age children suffer severe recurrent abdominal pain. But many children and adolescents go for 13 to 18 months before being treated, and some are never treated at all. In some cases, untreated pain is so debilitating that they miss school, dance classes, sports activities and social events. They are at risk of falling behind academically, physically, socially and developmentally. Experts say that organic causes like ulcers, inflammation or intestinal blockages are to blame in only a small minority of children, 5 to 10 percent. A majority suffer instead from what are called functional gastrointestinal disorders. The most common are functional abdominal pain, in which pain is the only symptom; irritable bowel syndrome, which brings on pain along with diarrhea or constipation; and functional dyspepsia, which typically shows up as pain with nausea or a feeling of fullness. Often, children who have recurrent abdominal pain are put through a battery of invasive tests. They are placed on restrictive diets and given large doses of acid-suppressing medications or anti-diarrhea drugs, which may offer some relief for the symptoms, but often do nothing for pain. Some children are told that their illness is "all in their head," or that they are faking it. According to gastrointestinal specialists, many doctors do not know how to treat stomach pain in children. "There are a lot of misconceptions that make the life of these children more difficult," said Dr. Carlo Di Lorenzo, chief of pediatric gastroenterology at Children's Hospital of Columbus, Ohio. "They bounce from doctor to doctor, get more and more tests, until things get better or they find a specialist who knows how to treat them," Dr. Di Lorenzo said. In fact, there are clear criteria for diagnosing disorders that cause recurrent abdominal pain, and for most children, the diagnosis can be made without invasive tests. "It's an easy diagnosis, but not for pediatricians, because they are still so lacking in their awareness that these conditions exist in children and adolescents," said Dr. Nader N. Youssef, a pediatric gastroenterologist at the Goryeb Children's Hospital in Morristown, N.J. New approaches to treating pain - including cognitive behavioral therapy; alternative treatments like relaxation techniques and massage therapy; and antidepressants - are already being used in adults, but they have not been widely adopted for children, in part because only a handful of small studies support such use. In recent years, however, experts have begun to understand more about the connections between the brain and the gut, a relationship that is reflected in popular expressions like "a gut-wrenching experience" or "having butterflies in your stomach." The gastrointestinal tract is awash in nerve cells and neurotransmitters. About 95 percent of the body's neurotransmitter serotonin is in the intestinal tract. Stress, nervousness, fear and other emotions often play out their own drama in the gut. In children with abdominal pain, the intestinal tract becomes hypersensitive to stimuli, with the slightest bit of gas, for instance, sending a flood of pain signals to the brain. The problem appears to be a mismatch in signaling between the brain and the gut, said Dr. Lonnie Zeltzer, director of the Pediatric Pain Program at the David Geffen School of Medicine at the University of California, Los Angeles. "If you have ongoing pain, you can develop abnormal pain pathways, so that the volume of pain signaling is being turned up and up," Dr. Zeltzer said. What causes the hypersensitivity is not completely understood, but experts believe that it is often set off by a stomach virus or an infection. "It's not uncommon that a family will get viral gastroenteritis, the whole family gets better except the child," said Dr. Zeltzer, whose book, "Conquering Your Child's Chronic Pain: A Pediatrician's Guide for Reclaiming a Normal Childhood," will be published by HarperResource in January. "The pain system is turned on and stays on." Experts do not know why some children and adolescents develop this problem and others do not. One clue may be that children with abdominal pain tend to be unusually worried and anxious. In a study published in the April issue of Pediatrics, researchers at the University of Pittsburgh interviewed children in a primary care setting and found that those with recurrent abdominal pain were 79 percent more likely to have an anxiety disorder than those in a control group. In turn, the pain can cause more worrying, leading to a vicious cycle. Treatment for these children often gets off on the wrong track. When children see their doctors, they are usually put through several tests to rule out more serious diseases. But many experts question the need for these tests, because cancer and other serious problems are uncommon in children, and are typically accompanied by other telltale symptoms like weight loss, vomiting, fever, blood in the stool or a rash. It is often parents' anxiety, said Dr. Di Lorenzo, that determines the extent of the work-up. Young patients are typically given medications to relieve the intestinal symptoms like diarrhea or constipation. About 60 percent of children receive some relief from these medications. "There's about 40 percent, though, that no matter what you do, the pain is their predominant feature, and you can't get them better with these drugs," Dr. Youssef said. As an understanding of the brain-gut connection grows, however, some centers have begun to use techniques like cognitive behavioral therapy, relaxation training, massage therapy and other alternative approaches as a first line of treatment. The effectiveness of these therapies is still debated, and the number of studies examining their effectiveness in children is very small, experts say. In one study published in the August issue of The Journal of Pediatric Gastroenterology and Nutrition, 18 children ages 8 through 17 who had pain for about a year were taught guided imagery and progressive relaxation. In four to seven sessions, 89 percent of the children reported a reduction in pain, to an average of two episodes a week, from six, said Dr. Youssef, the lead author of the study. The children had fewer missed school days, and their quality-of-life scores rose significantly. "Our goal is to help them relax about the pain," Dr. Youssef said. "If you don't worry about the pain, you don't get pain." Studies of relaxation methods and guided imagery in adults have shown similar results. But these alternative approaches face several obstacles. Some families do not want to consult a mental health professional for fear of stigmatizing their children, experts say. And alternative therapies typically are not covered by insurance. In addition, many centers do not have experts qualified to teach the techniques to children. Another novel approach is the use of antidepressants for the pain. An analysis of large studies of adults with functional abdominal pain found evidence for the effectiveness of low doses of tricyclic antidepressants, though the drugs have not been studied in children for such complaints. Tricyclics, an older class of antidepressants, have also been associated with rare cases of unexplained sudden death, and some doctors require an electrocardiogram before prescribing them to children. Newer antidepressants like selective serotonin reuptake inhibitors, or S.S.R.I.'s, are also being used, and the data are just beginning to show some benefits for abdominal pain. For those parents trying to help children cope with recurrent bellyaches, experts say it is important to understand that there does not have to be an organic reason for the pain, Dr. Zeltzer said. She advised parents to avoid unnecessary tests, because the tests themselves are stressful. She and other experts recommend that parents help children learn relaxation techniques like breathing methods, progressive muscle relaxation or visualization to use when they are feeling stressed. The techniques are explained on many Web sites. Children with recurrent stomach pain, experts say, should be kept in school and should stay involved in activities, if possible. These distractions help take the focus off the pain. Good sleep habits and exercise also help reduce pain. In Hannah's case, her mother took her to a pain management center in Kansas City, Mo., where she learned cognitive behavioral strategies to help change her reactions to stress and relaxation exercises to reduce the stress and pain. By late March, Hannah was back in school. "I think I stopped thinking about it and worrying about it," she said.


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