Recurrent Abdominal Pain of Childhood What is Recurrent Abdominal Pain of Childhood? Recurrent Abdominal Pain of Childhood is a syndrome (an experience) of abdominal discomfort that occurs in children in later childhood, typically between the ages of 8 and 12, and occurs in an otherwise normal and healthy child. It is not associated with any abnormal findings on laboratory tests, xrays and even at surgery. It is a real pain – not imaginary or psychological. It goes away usually at puberty and does not lead to anything else later in life. What are the typical symptoms of Recurrent Abdominal Pain of Childhood? Typically (not always), the pain is around the belly button and in the midline (not on one side or the other). The pain occurs at any time of the day but not usually waking the child up at night. The pain is not related to what is called visceral function – the working of the internal organs – so there is no rhyme or reason to the pain. In other words, the pain is not related to meals – it can occur before, during, shortly after or a long time after meals. It is not related to bowel movements in that is does not regularly occur before a bowel movement or after a bowel movement. It is not related to movement or activity. It is not related to urination. Nothing brings it on nor relieves it. The child tends to moan and groan with the pain but can rarely cry with the pain. The pain tends to occur at least weekly and often daily or several times a day. The child is otherwise well. How is Recurrent Abdominal Pain of Childhood diagnosed? Recurrent Abdominal Pain of Childhood is diagnosed on the basis of clinical symptoms. There are no tests that prove the diagnosis. Tests can only rule out other possible diagnoses. However, if the child presents with the symptoms described in the above section, it highly likely that all tests will be normal, and if they are abnormal, probably don’t relate to the pain.
The way the diagnosis is made is by the description of the pain and its relation to various bodily functions and activities. Each organ is considered in the evaluation of the pain. Diseases of the esophagus that cause pain, give pain behind the chest bone, typically after eating or waking from sleep in the middle of the night. Typically there is the experience of acid material coming into the throat. Esophageal pain is relieved by drinking milk, taking antacids or taking acid-reducing drugs. Stomach or duodenal pain is experienced when there is a lot of acid in the stomach. It is felt above the belly button and is very meal related - tending to occur before meals - or in the middle of the night. Drinking milk or taking antacids rapidly relieves stomach or duodenal pain. Small intestinal pain occurs when the small intestine is working. It is felt in the same mid-abdominal area (around the belly button) as does Recurrent Abdominal Pain of Childhood. However, small intestinal pain is very much meal related – occurring 15 to 60 minutes after a meal – and not occurring between meals. Colonic pain occurs when the colon is moving stool along. It is typically felt below the belly button, often on the left side, and occurs before and rarely after a bowel movement. It is relieved by a bowel movement. Gallbladder pain is a severe pain occurring above the belly button usually in the midline but also occurring to the right. It comes on infrequently (usually every few weeks or months), comes on severely, stays constantly for several hours often resulting in a visit to emergency. Pancreas pain is also a severe pain occurring above or around the belly button usually in the midline. It comes on infrequently (usually at least every few weeks), comes on severely, stays constantly for days often resulting in a visit to emergency.
Kidney pain occurs to the back and rarely gives abdominal pain. Bladder pain is very low in the abdomen, gets worse prior to peeing and is relieved by peeing. Gynecological pain is extremely rare in girls who have not entered puberty, and if present is felt very low in the abdomen. Recurrent Abdominal Pain of Childhood is diagnosed in the setting of an otherwise well child without any of the above descriptions to the pain, Concern as to whether the problem is really Recurrent Abdominal Pain of Childhood should be expressed if any of the following occurs: Weight loss Significant occurrence at night Diarrhea especially with blood Constipation as evidenced by large, hard infrequent stools Vomiting An otherwise ill child Rare, sporadic occurrence to the pain (less than weekly) What tests should be done for Recurrent Abdominal Pain of Childhood There is no test for Recurrent Abdominal Pain of Childhood. Tests are done to rule other things out. If reassurance is needed, the best test to do is visualizing the area of the area of concern by x-ray or ultrasound. If the pain is the typical pain around the belly button, then the easiest test to do is a small bowel follow-through - which is a good test for visualizing the small intestine – really the only organ that gives pain around the belly button. In this test, the child swallows flavoured barium and it is watched on x-ray. CT scanning can also be done but this has a lot of x- ray radiation involved – a concern in a young child if not obviously indicated. Another popular test among concerned parents (not by doctors for this problem) is an MRI but these are very hard to get and very difficult for children to tolerate given the fact that the child is placed in a tightly enclosed, noisy space, and to do it properly, often needs a large amount of material placed in the GI tract. What are the risks for Recurrent Abdominal Pain of Childhood?
Recurrent Abdominal Pain of Childhood is self-limited in that it goes away around puberty. It does not lead to anything else later in life. The medical only risk is if another cause of pain arises that is passed off as Recurrent Abdominal Pain of Childhood – such as appendicitis. The rule here is that if a different pain arises, and particularly if it is severe, it should be evaluated by a physician and not considered Recurrent Abdominal Pain of Childhood until diagnosed otherwise. The other risk is that the pain might dominate the child’s life, generally due to how their caregivers respond to the pain. Fortunately, this situation is unusual since children usually go right back to their activities once the pain goes away. Occasionally, like all pains and diseases, it can be an excuse for more attention by care providers, and can allow avoidance of activities the child is not keen on, e.g. school attendance. How is Recurrent Abdominal Pain of Childhood treated? There is no medical, surgical or psychological treatment of Recurrent Abdominal Pain of Childhood. The “treatment” is that of understanding that the pain is real, dealing with the pain as best as possible and letting the child have reasonable control over the pain situation. Pain medications such as Tylenol and Motrin generally don’t work, mainly because of the fact that by the time they are absorbed from the small intestine, the pain has gone. They can be effectively used to prevent the pain if a typical time of day is associated with the pain. If this is the case then giving these medications ½ hour before the expected time of the pain can be useful. The pain is real. It is like a headache but it is in the abdominal area. Proof of the pain being real can be witnessed by the child becoming pale or listless, or stopping their favorite activity. Acknowledging this and helping the child understand the pain is helpful. A little confession on my behalf: One of my children had Recurrent Abdominal Pain of Childhood. As a pediatric gastroenterologist, I had a hard time trying to tell whether the pain was real or they really didn’t want to go
to school. My approach was to let them decide how bad the pain was. If the pain was bad enough to stay home, then the best place for them was to be in bed, not watching TV or playing video games or whatever, but in bed so they could get better. If the pain wasn’t bad enough to stay home, then when they came home they had all of their “non-sick” privileges. There are two medications that are occasionally used if the Recurrent Abdominal Pain of Childhood is so bad that it interferes with all activities. These two medications are pain modifiers and do nothing to affect the cause of the pain. If necessary, one can use a small does of amitriptyline – an old anti-depressant that has pain relieving properties and some antispasmodic activity. It does have side-effects including sleepiness, interference with learning and dryness. Using a fairly substantial medication to treat a problem that will eventually go away is a concern. Some doctors use a drug called cyproheptadine. How this drug works is not clear but it has had some success in a few patients. Again it is a drug with significant potential side effects and few are comfortable using it. Are there any resources for Recurrent Abdominal Pain of Childhood? My website – kidstummies.com. Look for a Books for Children – Abdominal pain.