By Scholl, Jennifer Allen, Patricia Jackson
This article reviews the literature related to functional abdominal pain (FAP) in childhood, including the definition, etiology, contributing factors, clinical diagnosis, therapy and management, and associated long-term health effects. FAP is determined when no specific structural, infectious, inflammatory, or biochemical cause can be found in a child with chronic pain. The presence of abdominal pain as an isolated symptom is more suggestive of FAP, whereas multiple symptoms are more likely to be due to an organic or biochemical condition. While the exact cause of FAP is not completely understood, most researchers and clinicians agree that it is of multi-factorial etiology coupled with an altered brain- gut interaction. Children are highly susceptible to influences around them and can experience pain in response to normal childhood feelings and experiences. Psychological disorders such as anxiety and depression are common in both children with FAP and their parents. Children with FAP tend to have low levels of self- directedness, internalize their feelings and worries, and ruminate over issues they cannot control.
The biopsychosocial model has proved to be a worthwhile framework for children with FAP, as it recognizes the interaction between social and environmental influences, psychological processes, and the state of the body. Interventions that focus on the child’s cognitive processes associated with abdominal pain and the family’s response to the pain have increased efficacy over standard education and reassurance. Providing children and families with techniques to use when experiencing pain decreases alterations in normal daily activities and improves long-term health outcomes.
Chronic abdominal pain is a common complaint among children and adolescents in the primary care setting. While the current prevalence has not been determined, previous data report 2%-4% of all pediatric office visits are for the evaluation of abdominal pain (Starfield, Hoekelman, & Mc Cormick, 1984). Children may experience abdominal pain when they are worried or excited or hungry, but they may also complain when they have pain from an organic disorder or disease. Practitioners must be prudent in their approach, systematic and skilled to differentiate organic disease from benign conditions. A benign or functional disorder is typically determined when no specific structural, infectious, inflammatory, or biochemical cause can be found in a child with chronic pain (Subcommittee on Chronic Abdominal Pain [SCAP], 2005a).
Children with functional abdominal pain (FAP) typically present to the primary care office with peri-umbilical pain that has been occurring for 2 or more months and interfering with participation in normal childhood activities. While mild additional symptoms may be associated, abdominal pain is the most troubling symptom that will explain the child’s withdrawal from normal activities. The presence of abdominal pain as an isolated symptom is more suggestive of FAP, whereas multiple symptoms (listed in Table 1) are more likely to be due to an organic or biochemical condition (Saps & Li, 2006). It is important to recognize, however, that only 3%-8% of children with isolated abdominal pain lasting 3 or more months will have an organic cause for their pain (Kokkonen, Haapalahti, Tikkanen, Karttunen, & Savilahti, 2004; Miele et al., 2004; Schurman et al., 2005; Walker et al., 2004). Table 2 provides a list of differential diagnoses associated with chronic abdominal pain.
Background
The concept of “functional abdominal pain” (FAP) was first defined as “recurrent abdominal pain” (RAP) by John Apley in 1958 (Apley, 1975). Apley set forth criteria for RAP that continues to be used by practitioners today. The diagnostic criteria for RAP states that a child experiencing at least three bouts of abdominal pain within 3 months, with pain severe enough to interfere with normal functioning should be diagnosed with RAP. Apley did not detail the etiology of RAP, however, making it more of a symptom than a diagnosis. As research on RAP has progressed, it has become evident that different types or subgroups of abdominal pain exist.
In 1999 a group of pediatric gastroenterologists developed symptom-based criteria for functional gastrointestinal disorders (FGIDs) in children. The “Rome II criteria,” as it became known (based on the geographic location of the original meetings), clustered common pediatric gastrointestinal disorders based on their symptoms and clinical presentations (Rasquin-Weber et al., 1999). The abdominal pain category included the following diagnoses: functional dyspepsia, irritable bowel syndrome (IBS), abdominal migraine, functional abdominal pain, and aerophagia (Rasquin-Weber et al., 1999). Previously, functional disorders were default diagnoses, made only after the physical exam, laboratory and radiographic tests were normal. The Rome II criteria enabled clinicians to make functional diagnoses based on specific symptoms, retiring the notion that every possible disorder should first be ruled out before a functional diagnosis could be made. Diagnoses based on specific criteria reassure children and families that their symptoms correspond with a real, but not organic, diagnosis.
Rome II was the first attempt at categorizing FGIDs in children. Its application in the clinical setting has not been without its problems and criticisms. Research studies found 16%-35% of children previously fitting Apley’s RAP criteria did not fit any of the Rome II criteria (Caplan, Walker, & Rasquin, 2005; Schurman et al., 2005; Walker et al., 2004). According to a 2005 survey conducted by the North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHN) and the American Academy of Pediatrics (AAP), pediatric practitioners were unaware of the Rome II criteria for diagnosing FGIDs and misused terms related to chronic abdominal pain (SCAP, 2005a). Even 6 years after release, its clinical use and application was poor.
In 2006 the Rome committee met again to update the FGID categories and improve their clinical applicability. The criticisms and problems met with the Rome II criteria were addressed, resulting in a new and improved document, “Rome III” (see Table 3 for complete diagnostic criteria). The Rome III abdominal pain category continues to include functional dyspepsia, irritable bowel syndrome, abdominal migraine, and FAP, but now also includes a new diagnosis, “functional abdominal pain syndrome” (FAPS) (Rasquin et al., 2006). Children with FAP may experience episodic abdominal pain that does not interfere with their daily activities, while children with FAPS have a loss in daily functioning and additional somatic symptoms like headache, limb pain, and sleep disturbances (Rasquin et al., 2006). The Rome III criteria recognize the wide spectrum of children who present with functional, chronic abdominal pain by including both FAP and FAPS.
Prevalence
FAP is most commonly experienced by children between the ages of 8-15 years with the most common age of onset being 9 1/2 years (Campo, Bridge, et al., 2004; Huang, Palmer, & Forbes, 2000; Walker et al., 2004). It is uncommon under the age of 4 years (Saps & Li, 2006). The occurrence is slightly higher among females, with the female-tomale ratio increasing with age (Campo, Comer, Jansen McWilliams, Gardner, & Kelleher, 2002; Clouse et al., 2006; Crushell et al., 2003; Huang et al., 2000; Uc, Hyman, & Walker, 2006; Walker, Smith, Garber, & Claar, 2006). FAP may be more common in children from single-parent families (Campo, Bridge, et al., 2004; Uc et al., 2006), low socioeconomic status (Boey & Goh, 2001; Walker, Garber, & Greene, 1993), and low parental academic attainment (Boey & Goh, 2001; Campo et al., 2002; Perquin et al., 2000). However, these familial characteristics are not consistent throughout the research literature (Huang et al., 2000; Kaminsky, Robertson, & Dewey, 2006; Logan & Scharff, 2005; Malarty et al., 2005; Uc et al., 2006). Research on FAP has primarily included Caucasian children, but the occurrence of FAP in African American children has recently been identified (Uc et al., 2006; White & Farrell, 2006). Differences in race and ethnicity have not been well studied, although, it is clear that FAP is a global health problem (SCAP, 2005b).
Etiology
While the exact cause of FAP is not completely understood, most researchers and clinicians agree that it is of multi-factorial etiology coupled with an altered brain-gut interaction (Clouse et al., 2006; Drossman, 2006; Saps & Li, 2006). Children are highly susceptible to influences around them and can experience pain in response to these influences. Stress from school (Boey & Goh, 2001; Fekkes, Pijpers, & Verloove-Vanhorick, 2004; Greco, Freeman, & Dufton, 2006) and home (Boey & Goh, 2001; Levy et al., 2006; Logan & Scharff, 2005) increase the incidence of FAP. Even good stress, like anticipation and excitement about a birthday party or a dance recital, can exacerbate FAP symptoms.
The brain-gut connection suggests that children with FAP have differences in their central and enteric nervous systems, which cause bowel hyper-reactivity to stimuli, and results in abdominal pain (Jones, Dilley, Drossman, & Crowell, 2006). Physiologic stimuli (bowel motility, intestinal gas, hormonal changes), psychological stimuli (family dysfunction, anxiety, excitement), or other stressful stimuli (normal inflammatory processes) that would not normally cause pain can produce exaggerated symptoms in children with an altered brain-gut connection (SCAP, 2005a). In comparison to both healthy children and those with chronic disease, children with FAP report a lower pain threshold in response to painful stimuli on surfaces of the body (Duarte, Goulart, & Penna, 2000) and to increased intraluminal pressure using an inflatable balloon (DiLorenzo et al., 2001). Psychological disorders such as anxiety and depression are common in children with FAP (Ball & Weydert, 2003; Campo, Bridge, et al., 2004; Campo, Perel, et al., 2004; Crushell et al., 2003; Dorn et al., 2003; Huang et al., 2000; Kaminsky et al., 2006; Thomsen et al., 2002; White & Farrell, 2006). Children with abdominal pain for 3 months or longer and three or more nonspecific symptoms (headache, dizziness, chest pain, fatigue, back pain, weakness, racing heart) reportedly have a high incidence of depression (Little, Williams, Puzanova, Rudzinski, & Walker, 2007). Psychopathology does not substantiate a functional diagnosis over an organic diagnosis, however, as children with organic disorders reportedly experience anxiety and depression at the same rate as children with FAP (Dorn et al., 2003; Walker et al., 1993).
Children whose parents have functional gastrointestinal disorders, anxiety, depression, somatization, or other pain disorders are more likely to exhibit FAP than children whose parents do not have such disorders (Ball & Weydert, 2003; Huang et al., 2000; Kaminsky et al., 2006; Levy et al., 2004; Logan & Scharff, 2005). The familial influence appears to be a complex interaction between environmental influences (social learning, social support), psychological factors, and an inherited altered brain-gut connection (Levy et al., 2006).
Children with FAP tend to have low levels of self-direct-edness, internalize their feelings and worries, and ruminate over issues they cannot control (Campo, Bridge, et al., 2004). These children engage in passive coping strategies (isolation, catastrophizing, behavioral disengagement) in lieu of adaptive coping strategies (Kaminsky et al., 2006; Lipani & Walker, 2006; Thomsen et al., 2002; Walker et al., 2006) and have difficulty directing their attention away from negative stimuli and pain (Boyer et al., 2006; Thomsen et al., 2002). Because many children with FAP do not activate effective coping mechanisms in the presence of stimulation or threat, they enter into a spiral of stress, worry, pain, rumination about the pain, worsening pain, stress, worry…until it becomes debilitating. In the presence of a psychological diagnosis, such as anxiety, children may experience even greater disability and alteration in their normal daily activities, resulting in functional abdominal pain syndrome (FAPS).
Altered Activities of Daily Living
Functional abdominal pain can lead to significant dysfunction and disability, resulting in school absences (Campo et al., 2002; Crushell et al., 2003; Walker, Claar, & Garber, 2002), withdrawal from social activities (Blanchard, Gurka, & Blackman, 2006; Crushell et al., 2003; Lipani & Walker, 2006; Walker et al., 2002), and disruption in family functioning (Hunfeld et al., 2002; Lipani & Walker, 2006; Logan & Scharff, 2005). Multiple visits to healthcare providers in and of itself can cause a child to miss school and parents to miss work. Children and families experiencing unexplained abdominal pain have also been found to have fear associated with the condition, especially when they suspect a serious disease has been missed by their practitioner (Crushell et al., 2003; van Tilburg & Whitehead, 2003). In general, children and parents report low levels of quality of life in comparison to healthy controls (Youssef, Murphy, Langseder, & Rosh, 2006).
Children with abdominal pain have a high utilization of the health care system as they seek an explanation for and relief from their pain (Campo et al., 2002; Greco et al., 2006; Lindley, Glaser, & Milla, 2005). Children with FAP reportedly visit at least three different health care providers for evaluation of unexplained abdominal pain (Campo et al., 2002; Caplan et al., 2005). In attempt to reach a diagnosis, practitioners may order a series of blood tests, radiological studies, endoscopies, and other invasive procedures. Studies evaluating the standard of practice have found that practitioners often order diagnostic tests and refer to specialists, against their better judgment, at the insistence of parents (Lindley et al., 2005). Unexplained abdominal pain accounts for up to 25% of referrals to tertiary gastroenterol-ogy clinics (Boyle, 1997). National estimates of hospital utilization by children show gastrointestinal disorders, including abdominal pain, as the leading cause of hospitalizations (Guthery, Hutchings, Stat, Dean, & Hoff, 2004).
Children with FAP have been found to have long-term associated health problems into adulthood. Adult irritable bowel syndrome (IBS) was identified as a long-term outcome of FAP over 30 years ago (Christensen & Mortensen, 1975) when data was gathered from adults who had experienced childhood FAP. Twenty years after initial presentation with FAP, 61% of patients experienced symptoms consistent with IBS. More recent studies have also identified the link between childhood FAP and adult IBS, but to a lesser extent; 18%-25% of children developed IBS in adulthood (Blanchard & Scharff, 2002; Jarrett, Heitkemper, Czyzewski, & Shulman, 2003; Walker, Guite, Duke, Barnard, & Greene, 1998). Physiological abnormalities, bowel hyper-reactivity, and psychological issues associated with childhood FAP may persist and worsen into adulthood, resulting in altered bowel movement frequency and/or consistency, associated with IBS (Jarrett et al., 2003).
Just as there is a spectrum of FAP severity, there is also a spectrum of long-term health outcomes. One longitudinal study found adults with a history of FAP were significantly more likely than controls to experience anxiety, hypochon-driasis, social dysfunction, somatization, and were more likely to be taking psychoactive medication (Campo et al., 2001). On the other hand, many children reportedly have complete resolution of their symptoms within months of diagnosis and others within 2-5 years (Mulvaney, Lambert, Garber, & Walker, 2006).
Assessment/Diagnosis
Caring for children with nonspecific, recurring abdominal pain is a challenge. A detailed evidence-based guideline for assessment and diagnosis will provide an organized course for practitioners, children, and families to follow. The biopsy-chosocial model has proved to be a worthwhile framework as it identifies the interaction between social and environmental influences, psychological processes, and the state of the body (Engel, 1977). The pediatric nurse practitioner can evaluate for organic disease while simultaneously identifying significant psychosocial influences by using this model of care throughout the evaluation (Cunningham & Banez, 2006; Levy et al., 2006).
History. The initial evaluation of a child with nonspecific abdominal pain will include a comprehensive history: past medical history, family medical history, psychological issues, and social influences. Any of these systems can trigger, exacerbate, or worsen a child’s abdominal pain. As parental and child reports of pain vary depending on the child’s gender and age, the nurse should talk to the child first and inquire about the symptoms he has been experiencing (Ball & Weydert, 2003; Hunfeld et al., 2002; Mulvaney et al., 2006). Using the “OLD CARTS” pneumonic (Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, Severity) is helpful to assure the pain is being adequately described. During the history, the pediatric nurse practitioner should note the child’s affect and behavior, being sensitive to signs of anxiety or depression.
Next, obtain information from the parent(s) and identify additional symptoms, observations, or concerns. Include questions about specific food intolerance, bowel patterns, sleep disturbances, lifestyle changes, treatments, and level of participation in normal activities. The nurse can help the family identify what specifically worries them and what they think could be causing the pain. This portion of the initial evaluation purposefully includes the child and parent(s) as active participants in the evaluation of abdominal pain, and will provide valuable insight regarding the family dynamics. The nurse practitioner should briefly review the child’s past medical history, current medications, food and drug allergies, growth and development, psychological diagnoses, past social stressors, and any additional care received for abdominal pain.
Psychosocial Assessment
School. The child’s social situation and social comfort can often be determined by asking about the child’s school function. Children with FAP tend to miss a lot of school and other social activities, so the pediatric nurse should inquire about the number of missed days of school in the past month due to abdominal pain (this is a valuable outcome measure). There is a higher incidence of hospital admissions for nonspecific abdominal pain during the academic year than during holiday periods (Williams, Jackson, Lambert, & Johnstone, 1999). Children may worry about a school examination, a school dance, an important sports competition, or an encounter with a peer. For a child who is frequently absent from school, the practitioner should ask specific questions about the child’s school day and outline the daily experience class-by-class. Children who excessively push themselves to achieve high academic standards (Ball & Weydert, 2003), and children who are bullied at school (Boey & Goh, 2001; Fekkes et al., 2004; Greco et al., 2006) have a higher reported incidence of FAP than their unaffected counterparts. In addition, self-imposed isolation from peers may be symptomatic of anxiety or depression (Kaminsky et al., 2006). Negative life events. Children with FAP who experience either major negative life events (personal hospitalization, the hospitalization of a family member, and a change of parental occupation) or minor daily irritants have an increase in the frequency of pain complaints (Boey & Goh, 2001; Walker et al., 2006; White & Farrell, 2006). Daily stressors include anything that is troublesome or unusual to the child (chores, homework, sibling interaction). Children with FAP have not been found to experience negative life events more frequently than other children, but their ability to use effective coping strategies in the face of stress is weak (Boyer et al., 2006; Campo et al., 2002; Walker et al., 2006). Therefore, the pediatric nurse should inquire about significant events, changes in the child’s life, and sources of daily stress. The child should identify daily experiences that make him excited, worried, frustrated, nervous, or scared, and what he does when faced either with the encounter or the anticipation of the encounter.
Abuse. The nurse practitioner should evaluate for physical and sexual abuse throughout the assessment and work-up, as childhood abuse has been related to functional gastrointestinal disorders throughout the lifespan (Levy et al., 2006). The reported rate of sexual, physical, and emotional abuse in individuals with functional gastrointestinal disorders has been reported as high as 30%-56% (Levy et al., 2006).
Family functioning. Family conflict and the presence of parent/ child enmeshment are closely linked to the level of dysfunction associated with abdominal pain (Blanchard et al., 2006; Campo et al., 2002; Kaminsky et al., 2006; Lipani & Walker, 2006; Logan & Scharff, 2005; Walker et al., 1993). In contrast, an adaptive family environment may be protective against loss of daily functioning (Logan & Scharff, 2005). The provider should inquire about how family members respond to the child’s pain complaints and the impact it has on the family functioning. Parental attention to pain complaints through worry, reward, increased attention or interest may encourage associated pain behaviors (Kaminsky et al, 2006; Lipani & Walker, 2006; Logan & Scharff, 2005; Walker et al., 2002).
Family Medical History
The family medical history can give insight into pain disorders, functional and organic gastrointestinal disorders, and psychological conditions that run in the family. The nurse practitioner should discuss the role of family medical history openly, being especially sensitive to psychological conditions that parents may be reluctant to share. Children whose parents have functional gastrointestinal disorders reportedly have more abdominal pain complaints, school absences, medical office visits, and daily dysfunction than controls (Levy et al., 2006).
Review of Systems
A thorough review of systems should be completed to identify symptoms not previously mentioned. If the child is reporting additional symptoms, the process of evaluation will need to be expanded to include suspected organic conditions. Even if the practitioner suspects FAP, the diagnostic process must be dynamic and flexible.
Physical Examination & Laboratory Assessment
The physical examination begins with the child’s growth chart, assessing for the growth pattern and consistency. Children with alterations in their growth pattern should be closely evaluated for an organic disorder. A head-to-toe assessment of a child with FAP should reveal a remarkably normal examination, with mild, nonspecific, peri-umbilical or slight epigastric abdominal pain upon palpation. The further the pain is away from the umbilicus, the less likely the diagnosis is functional (Apley, 1975). Additional abnormal physical findings may indicate the need to evaluate the child further for organic conditions other than FAP.
To date, there are no studies that have evaluated the usefulness of common laboratory tests to distinguish between functional and organic abdominal pain (SCAP, 2005b). It is reasonable to obtain a few laboratory tests during the initial evaluation of nonspecific abdominal pain. These should include a complete blood count with differential, erythrocyte sedimentation rate, urinalysis and urine culture, stool sample for occult blood, and additional stool studies (ova and parasite, culture) if diarrhea is present (SCAP, 2005b; Saps & Li, 2006). Additional laboratory studies should be carefully considered on the basis of the history and physical examination, but are typically not necessary for FAP diagnosis. Ordering multiple laboratory tests is costly and may encourage ideas of a “mystery disease” lurking in the body. Discussion of the plan of care with the family and child should highlight the possibility that all of the laboratory values may be normal, but they may help guide the practitioner toward a diagnosis.
If the physical examination and laboratory tests are normal, and the child has a psychosocial history associated with FAP, imaging studies may not be necessary. However, if the presentation is not completely clear, an ultrasound of the abdomen and pelvis may be a useful examination. Sonography is usually a cost-effective way to exclude non-intestinal origins of the pain (SCAP, 2005b). However, in the absence of additional symptoms, ultrasound abnormalities have been found in less than 1% of FAP cases (Yip, Ho, Yip, & Chan, 1998). Additional laboratory, radiological, and procedural testing should be utilized with astute judgment, and based on specific clinical symptoms. The strength of a functional diagnosis should be based on positive findings, not on a series of negative ones.
Treatment/Therapy
Reassurance and education. The “standard” treatment for FAP is reassurance (Blanchard & Scharff, 2002; Cunningham & Banez, 2006). According to this standard, practitioners must reassure families and children that no organic disease is present and that the pain will resolve with time. However, an increased amount of research on FAP is suggesting that reassurance does not meet the needs of the child or the family. The impact of psychological and psychosocial issues, the concept of altered brain-gut connection, and the potential longevity of FAP make reassurance only one part of treatment and therapy for FAP.
Educating parents and children about FAP is essential. Families must understand the diagnosis before they accept it and participate in the plan of care. Functional diagnoses do not fit into a simple pathophysiologic model, which may be troubling or confusing for families. Children whose parents accept the biopsychosocial approach to care are reportedly more likely to have symptom improvement and/ or resolution (Claar & Walker, 1999; Crushell et al., 2003; Levy et al., 2006). It is important to resolve any misconceptions that the child is faking his pain and the pain is “all in his head.” Comparing the child’s abdominal pain to a headache may help parents understand that the child can experience pain in the absence of abnormal laboratory and/or physical findings (Saps & Li, 2006). Initially, parents and children should be instructed to use daily diaries to record the pain experiences, in an attempt to connect the abdominal pain with associated circumstances (Ball, Shapiro, Monheim, & Weydert, 2003; Cunningham & Banez, 2006; Drossman, 2006).
Parental training. Parents play an important role in the FAP treatment plan and must accept this responsibility for successful outcomes. Nurse practitioners must educate parents about FAP, including instruction on responding to pain complaints and behaviors. Parents who reinforce well behaviors with social attention (praise) and token rewards (stickers or points on a chart), ignore nonverbal pain behaviors, and promote distracting activities reportedly have children with fewer pain reports over time (Claar & Walker, 1999; Crushell et al., 2003; Sanders et al., 1989; Sanders, Shepherd, Cleghorn, & Woolford, 1994). Parents should also be instructed on the concept of social learning and the effect their own symptom behaviors can have on their children.
Parental beliefs regarding FAP affect symptoms and long-term outcomes for children. Parents who deny the possible connection between psychological factors and FAP have children with prolonged abdominal pain symptoms, whereas parents who identify the connection are more likely to have children with resolved symptoms (Crushell et al., 2003). Only about one-half of mothers interviewed by Claar and Walker (1999) endorsed both psychological and physical factors as important influences on their child’s FAP. Regularly inquiring about psychosocial issues and explaining their correlation to the body’s functioning will help parents identify the connection and allow them to better understand the functional pain pathway.
Diet. Dietary changes have lead to little improvement in FAP, as improvements in pain with dietary changes would most likely indicate an organic etiology for pain. While fiber has been shown to be an effective treatment for irritable bowel syndrome (IBS), its effect on FAP symptoms has not been as promising (Weydert, Ball, & Davis, 2003). Fiber supplementation is a safe and effective bowel maintenance regimen, but should not be relied upon for abdominal pain relief. Children with FAP who implement a lactose-free diet, without proven lactose intolerance, also do not have decreased abdominal pain (Weydert et al., 2003). Eliminating food groups from a child’s diet without an associated diagnosis could potentially impair growth and development.
Pharmacotherapy. There is limited evidence-based knowledge for the use of pharmacological interventions for childhood FAP. To date, few randomized, controlled trials of interventions have been conducted for children with FAP, and evidence of the efficacy of any treatment is lacking (Campo, 2005). Despite the lack of evidence for pharma-cotherapy, a substantial proportion of practitioners report prescribing pharmacological interventions for FAP (Campo, 2005; Huertas-Ceballos, Macarthur, & Logan, 2004). Commonly prescribed therapy includes analgesics, antihistamines, serotonergic agents, anticholinergics, antiemetics, antidepressants, anxiolytics, and antispasmodics (Campo, 2005). While pharmacological interventions are easily implemented and often requested by families, practitioners should prescribe medication with caution. Campo, Perel, et al. (2004) evaluated the efficacy of citalopram (selective serotonin reuptake inhibitor approved for the treatment of depression) in the treatment of FAP in children with comorbid internalizing disorders. In this nonrandomized, non-placebo- controlled clinical trial, abdominal pain and functional status improved with medication use. In the presence of an underlying depressive or anxiety disorder, citalopram may prove to be a useful therapy for FAP. Currently there are warning labels on citalopram instituted by the Food and Drug Administration (FDA), due to possible depressive and suicidal tendencies associated with its use in adolescents (FDA, 2004).
Tricyclic antidepressants (TCA) are reportedly prescribed for the treatment of FAP, based on anecdotal evidence only (Campo, 2005). The use of TCAs in children and adolescents, however, has been associated with undesirable side effects and carries an additional risk of sudden death (Varley, 2001).
Famotidine (H-2 receptor antagonist) is useful for functional dyspepsia or epigastric abdominal pain (See, Birnbaum, Schechter, Goldenberg, & Benkov, 2001). Pizotifen (serotonergic agent) has been found to improve abdominal migraine symptoms in school-aged children, but has not been used with FAP (Symon & Russel, 1995). Recently, medications that interrupt serotonergic neurotransmission in the gut have been shown effective in adults with IBS. These medications (alosetron and tegaserod) have not been studied in children and should not be considered for FAP treatment (Campo, 2005). Anticholinergic medications like dicyclomine and hyoscyamine have been used for their antispasmodic properties (Cunningham & Banez, 2006), but have also not been studied in children (Huertas Ceballos et al., 2004; Campo, 2005).
Complementary and alternative medicine. Complementary and alternative medicine (CAM) and herbal supplementations are possible therapies for children with FAP. When conventional medications and therapies are not effective, parents are likely to seek help from an alternative source (Sanders et al., 2003). In a survey given to parents of children with a chronic illness, 64% of respondents had used a least one form of CAM in the child’s treatment (Sanders et al., 2003). The type of interventions varied, but approximately 20% used oral herbal supplementations. Common herbal supplementations used for gastrointestinal upset are camomile, ginger, lemon balm, licorice, and peppermint (Vessey & Rechkemmer, 2001). However, the only randomized, double-blind control study done was conducted on peppermint oil and IBS; 71% of children in the peppermint treatment group reported improved abdominal pain after a 2-week trial (Kline, Kline, DiPalma, & Barbero, 2001). Herbal supplementation should be utilized with caution, since it is not regulated by the Food and Drug Administration (FDA) and can have potential undesirable side effects in children.
Alternative therapies. Alternative therapies such as relaxation, guided imagery, hypnosis, biofeedback, and self-talk practices are showing promising results with childhood FAP. These interventions provide outlets for children, aiming to teach them effective management strategies for stressful situations, maladaptive or distorted thinking, and pain perception. Guided imagery and relaxation techniques reportedly decrease the frequency of abdominal pain, missed school days, missed social activities, and contacts with primary care office (Ball et al., 2003; Youssef et al., 2004).
Using these techniques, a child is taught the difference between tense and relaxed muscles, and how the imagination can control what the body does and how it feels. Once relaxed, the child imagines the pain as an object or a symbol, describing it in great detail. After the pain has sufficiently been described, the child imagines something to get rid of or destroy the pain, and then they allow the destruction to occur (Ball et al., 2003). Children are encouraged to practice these techniques at home. Long-term improvement in abdominal pain complaints is found with continued use of mind-body skills performed in the home setting (Ball et al., 2003).
Self-hypnosis, a technique similar to muscle relaxation, is linked with improved FAP symptoms and outcomes. Following a session of hypnotherapy instruction, abdominal pain complaints were resolved within 3 weeks in 4 out of 5 children (Anbar, 2001). While research supporting self-hypnosis utilization is limited, it is a relatively easy technique that can be used in the primary care setting. During self-hypnosis a child imagines a relaxing place, relaxes from head to feet, and then chooses a symbol that reminds them of the state of relaxation. When faced with stress or abdominal pain, children can use the symbol to prompt their mind to focus on relaxing the body.
Any activity or practice that provides an outlet of coping for children with FAP has potential treatment efficacy. Primary care providers can teach children basic techniques such as deep- breathing exercises, muscle relaxation, distractive thinking, positive self-talk, self-hypnosis, and imagery. A child may benefit from turning down the lights and listening to soothing music in a comfortable place once daily. A calm, soothing environment uses the brain-gut connection and reduces the stimulation of the autonomic nervous system (Drossman, 2006). In addition, art, dance, and music therapy can be effective interventions for children with pain, depression, or anxiety (Pratt, 2004; Savins, 2002). It is important to develop an individualized plan that best suits the personality and interests of the child and family.
Cognitive behavioral therapy. The treatment option that has received the most attention in recent research is cognitive behavioral therapy (CBT). CBT is a form of psychotherapy that focuses on identifying cognitive processes that underlie maladaptive behaviors or disturbed emotions (Waite, 2006). Through a structured treatment plan, a trained CBT practitioner guides the child to uncover experiences, ideas, feelings, or beliefs (schema) that influence a specific behavior (Freeman, 2006). Once the schema is identified, the practitioner helps the child explore alternative explanations and responsive behaviors that will offset the former behaviors (Freeman, 2006). CBT does not aim to identify why certain behaviors occur, but to learn how thoughts, feelings, and subsequent behaviors interact (Freeman, 2006). CBT is present-oriented, problem- focused, structured, directive, educative, time-limited, and active therapy (Waite, 2006). This therapy can equip children and families with specific tools and techniques to change the thought processes and behaviors that result in abdominal pain and altered daily activities.
The most extensive research to date on CBT and FAP has been conducted by Sanders and colleagues (Sanders et al., 1989, 1994), who evaluated the effectiveness of a cognitive behavioral family intervention. A series of six intervention sessions provided an explanation of FAP and rationale for pain management procedures, training for parents on responsiveness to pain, coping skills and CBT training for children. Parental response techniques were as follows: to reinforce well behavior (attention, praise, rewards, points), offer distracting activities in response to verbal pain complaints, ignore nonverbal pain behaviors, avoid modeling sick role behaviors, and identify the difference between FAP complaints and those requiring further medical attention. Children were taught muscle relaxation, deep-breathing exercises, positive self-talk, distraction, and imagery skills they could use when experiencing pain. The CBT portion focused on teaching children techniques to interrupt distorted or maladaptive thought processes that would result in abdominal pain. When compared with standard pediatric care (reassurance and education), the children undergoing CBT had a higher rate of complete elimination of pain, lower levels of relapse at 6-and-12-month follow-up, and lower levels of disruption in their normal activities.
The effectiveness of family-based CBT sessions versus standard care was also demonstrated by Robins, Smith, Glutting, and Bishop (2005), using a double-blind, randomized study design. Children and families in the treatment group participated in five therapy sessions and homework assignments that aimed to improve their understanding of pain and associated behaviors. Specific goals were set for each session as children learned to “take control” of abdominal pain and parents learned to be active participants in the management of pain. Children and parents in the CBT group reported significantly less child-reported abdominal pain immediately following the intervention and at the 1 year follow-up. Children in the treatment group also had fewer school absences following the training.
CBT practitioners are required to undergo training in administration of the specific therapy, which is not always an option for primary care providers. However, the foundation of the therapy and the constructs that guide it can be borrowed as practitioners care for children in the primary care setting.
Plan of Care
A thorough, unhurried approach will support the development of an effective, individualized plan of care. Practitioners should establish guidelines and expectations early in the therapeutic relationship, so families recognize their important role in the plan of care. Parents should be educated that FAP is not a “disease” for the practitioner to “cure.” Practitioners need to emphasize the collaborative nature of the treatment process to parents and children (Campo & Fritz, 2001). By working together, an effective plan of care can be established, one that will be feasible in the given social and familial environment. The following is a sample treatment plan for FAP that can be implemented after the initial assessment session(s) are completed (see Table 4). It is important to identify children who may require referral to a gastroenterology or psychology specialist throughout the assessment and therapy sessions. Conclusion
FAP is a complex condition to manage in the primary care setting, but with the proper approach it is feasible. Children and their families require a calm practitioner who will obtain a thorough history and openly discuss psychosocial influences and the brain- gut connection. Laboratory specimens, radiological testing, and additional diagnostic procedures should be utilized with astute clinical judgment, and coupled with the notion that the results may be normal.
Educating families about functional gastrointestinal disorders and how to manage FAP symptoms at home is imperative. Parental training, alternative therapies, and cognitive behavioral techniques should be implemented as standard care for children with FAP. Empowering families with these tools will decrease alterations of normal daily activities and improve the long-term health outcomes for children with FAP. By using the provided sample plan of care, practitioners can feel confident in their ability to successfully manage FAP in the primary care setting.
The Primary Care Approaches section focuses on physical and developmental assessment and other topics specific to children and their families. If you are interested in author guidelines and/or assistance, contact Patricia L. Jackson Allen at [email protected].
Table 1. Signs and Symptoms Suggestive of Organic Disorder Associated with Abdominal Pain
History
* Age of onset before 5 years of age
* Localized pain away from umbilicus
* Additional gastrointestinal symptoms-significant vomiting (bloody or bilious emesis), chronic severe diarrhea, blood in stool, rectal bleeding
* Systemic symptoms-fever, weight loss, growth failure
* Extraintestinal symptoms-arthritis, arthralgias, aphthous ulcers, rashes
* Symptom resolution with dietary changes- elimination of lactose, wheat, carbohydrates
* Pain awakening child at night
* Family history of inflammatory bowel disease or peptic ulcer disease
Physical examination
* Abdominal mass or distention
* Hepatosplenomegaly
* Costovertebral angle tenderness
* Tenderness over spine
* Perianal abnormalities-fissures, ulceration, skin tags
* Oral lesions
* Joint swelling, redness
Laboratory
* Anemia
* Elevated erythrocyte sedimentation rate
* Elevated aminotransferases
* Hypoalbuminemia
* Abnormal urinalysis or culture
* Positive stool guaiac
Note: Adapted from Subcommittee on Chronic Abdominal Pain, 2005a; Saps & Li, 2006
Table 2. Differential Diagnoses: Chronic Abdominal Pain
* Abdominal migraine
* Abuse: physical, sexual
* Allergic eosinophilic gastroenteritis
* Anatomic abnormalities: intestinal malrotation, stricture, recurrent intestinal obstruction
* Appendiceal colic
* Carbohydrate malabsorption: lactose, fructose, sorbitol
* Celiac disease
* Constipation/stool retention
* Gastritis
* Gastroesophageal reflux
* Gynecological: dysmenorrhea, ovarian cysts, mittelschmerz, tuboovarian abscess, ovarian/uterine tumor, endometriosis, pelvic inflammatory disease, genital tract obstruction, adhesions, undescended testicle, hernia
* Hepatobiliary: hepatitis, tumor, abscess, cholecystitis, choledochal cyst, gonococcal perihepatitis
* Helicobacter pylori
* Hiatal hernia
* Infectious gastroenteritis: giardia, salmonella, shigella, yersinia enterocolitica, viral
* Inflammatory bowel disease
* Irritable bowel syndrome
* Lead poisoning (or other heavy metals)
* Lymphoma
* Meckel’s diverticulum
* Medication side effect (nonsteroidal anti-inflammatory drugs, antibiotics)
* Musculoskeletal disorder: muscle pain, discitis, linea alba hernia
* Pancreatitis
* Somatoform disorder
* Urinary dysfunction: urinary tract infection, hydronephrosis, ureteropelvic junction obstruction, nephrolithiasis
Note: Adapted from Boyle (1997); Dern (1999); Smith (2001).
Table 3. Rome III Criteria: Abdominal Pain Related Functional Gastrointestinal Disorders
Functional Dyspepsia
Must experience ALL of the following symptoms, at least once per week for at least 2 months:
1. Persistent or recurrent pain or discomfort centered in the upper abdomen (above umbilicus)
2. Not relieved by defecation or associated with the onset of a change in stool frequency or form
3. No evidence of an inflammatory anatomic, metabolic, or neoplastic process explains the symptoms
Irritable Bowel Syndrome
Must experience ALL of the following symptoms, at least once per week for at least 2 months:
1. Abdominal discomfort (an uncomfortable sensation not described as pain) or pain associated with 2 or more of the following at least 25% of the time:
a. Improved with defecation
b. Onset associated with a change in frequency of stool
c. Onset associated with a change in form (appearance) of stool
2. No evidence of an inflammatory, anatomic, metabolic, or neoplastic process explains the symptoms
Abdominal Migraine
Must experience ALL of the following symptoms, at least 2 times in the preceding 12 months:
1. Paroxysmal episodes of intense, acute periumbili-cal pain that lasts for 1 hour or more
2. Intervening periods of usual health lasting weeks to months
3. The pain interferes with normal activities
4. The pain is associated with two or more of the following:
a. Anorexia
b. Nausea
c. Vomiting
d. Headache
e. Photophobia
f. Pallor
5. No evidence of an inflammatory, anatomic, metabolic, or neoplastic process explains the symptoms
Functional Abdominal Pain
Must experience ALL of the following symptoms, at least once per week for at least 2 months:
1. Episodic or continuous abdominal pain
2. Insufficient criteria for other functional gastrointestinal disorders
3. No evidence of an inflammatory, anatomic, metabolic, or neoplastic process that explains the symptoms
Functional Abdominal Pain Syndrome
Symptoms occur at least once per week for at least 2 months. Abdominal pain symptoms must comprise 25% of pain complaints, in addition to 1 or more of the following symptoms:
1. Some loss in daily functioning
2. Additional somatic symptoms such as headache, limb pain, or difficulty sleeping
Note: Adapted from Rasquin, DiLorenzo, Forbes, Guiraldes, Hyams, Staiano, & Walker (2006).
Table 4. Plan of Care
Visit 1: Initial Assessment
1. Obtain complete history, physical exam, laboratory tests (as appropriate).
2. Introduce functional gastrointestinal disorders and the role of the brain-gut connection.
3. Instruct family and/or child to keep daily diary of pain, including circumstances surrounding pain complaints.
4. Schedule subsequent visit in 1-2 weeks.
Visit 2: Reassurance & Education
1. Review pain dairy: look for patterns, psychosocial stressors, and associated symptoms.
2. Reassurance and education:
* Review any laboratory or radiological testing performed.
* Reassure that there is no serious or life-threatening disease present in the body. Explain that while the child has real pain, the pain is not associated with actual tissue damage.
* Address any worries or questions the parent or child may have associated with pain experiences.
* Provide an explanation of the biopsychosocial model, addressing the connection between the child’s mind, environment, and body. Discuss inadvertent reinforcement of pain behaviors and how they can contribute to the frequency of pain complaints.
* Discuss the brain-gut connection, addressing the concept of a hyper-reactive bowel in the presence of normal stimuli.
* Discuss family patterns of hyper-reactive bowel symptoms and the role of behavior modeling in symptom patterns in children.
3. Self-regulation skills training
* Introduce self-regulation skills and their role in FAP therapy.
* Use clinical judgment to help child and family select an appropriate method (muscle relaxation, imagery, self-hypnosis, art, dance).
* A combination of methods is often used, depending on the child and the situation.
* Consider tape-recording the sequences as you instruct the child for the first time in the office. The tape should be about 10 minutes long and should be a tool for the child to practice self- regulation techniques at home.
* The session should prompt the child as he practices his self- regulating techniques at home.
* Establish a home practice schedule, including time and place (once per day should be a firm commitment, with an optional second practice per day).
4. Conclude the visit.
* Praise the child for his efforts.
* Review practice recommendation with parents.
* Instruct the child and parent to continue daily pain diaries.
* Set realistic expectations and goals, such as improved quality of life rather than complete pain resolution.
* Schedule subsequent visit in 1-2 weeks.
Visit 3: Self-regulation Skills & Parental Training
1. Review pain diaries, relaxation tape practice, and other clinical information.
* Inquire about new symptoms, stressors, thoughts about FAP and the therapy.
* Inquire about participation in daily activities and school.
2. Review importance of compliance with self-regulation practice at home. Review techniques with child as needed.
* Adjust self-regulation techniques as needed.
* Introduce idea of using self-regulation techniques in presence of pain. 3. Introduce appropriate pain behavior management guidelines for parents.
* Parents should model pain behavior management for own pain symptoms as appropriate.
* Parents should encourage normal activity.
* Express frequent approval for maintaining activity patterns, use tokens or stickers on chart for recognition.
* Advocate daily school attendance or stay in school as the norm.
* Discourage pain behaviors and redirect child’s attention.
* Ignore excessive complaining, pain gestures, and request for special treatment and assistance.
* Dispense medications for symptom relief, as necessary.
* Evaluate whether the consequence of the pain behavior is to avoid or escape from an activity or situation. If so, consider maintaining things as they are or introducing an alternative that has little appeal to the child (lay down in bed).
* Avoid questioning about presence of pain or status of pain.
* Educate school officials and teachers, as appropriate.
* Schedule subsequent visit in 1-2 weeks.
Visits 4 & 5: Cognitive Behavioral Techniques
1. Review pain diaries, relaxation tape practice, and other clinical information.
* Inquire about new symptoms, stressors, thoughts about FAP and the therapy.
* Inquire about parental training, parental symptoms (if appropriate), and associated challenges or questions.
* Inquire about participation in daily activities.
2. Review self-regulation techniques and its effectiveness with pain symptoms.
* Decrease practice sessions as competence is achieved.
3. Introduce cognitive behavioral therapy techniques.
* Discuss the child’s cognitive processes surrounding pain experiences. Ask the child to explain why he thinks he has pain, what is happening in his body, what he thinks the result of pain is, past associations with pain.
* Together with the child, identify a specific thought or idea to change regarding his pain experiences.
* Help the child explore alternative explanations and responsive behaviors.
* Incorporate self-regulation techniques.
* Review the techniques and how the child can utilize them in the presence of pain.
* Role-play a pain scenario. Pain presents…child captures maladaptive thought or idea, thinks of the new alternative explanation for pain…uses self-regulating techniques to support behavioral change.
4. Assign homework for child and parents.
* Continue pain diaries.
* Think of new responses to situations discussed in therapy session.
* Try cognitive behavioral techniques at home.
* Continue to identify sources of pain exacerbation.
* Encourage health promoting behaviors (healthy eating, exercise, socialization)
* Schedule subsequent visit in 1-2 weeks.
Visit 6: Problem Solving
1. Review pain diaries, relaxation tape practice, cognitive behavioral techniques, and other clinical information.
* Inquire about new symptoms, stressors, thoughts about FAP and the therapy.
* Inquire about participation in daily activities and school.
2. Review cognitive behavioral techniques and discuss effectiveness with pain symptoms.
* Identify barriers to compliance with plan of care.
3. Role-play specific scenarios or situations that have exacerbated pain symptoms in past week.
* Problem solve with child and parent, providing guidance for high-risk situations.
4. Child and family should continue with current treatment plan.
* Schedule follow-up appointment 4-6 weeks after the last treatment session.
* Schedule additional follow-up appointments at 3-6 month intervals, as appropriate.
Subsequent visits
1. Review cognitive behavioral techniques.
* Modify techniques as appropriate for child and family.
* Encourage continuation of techniques, even if symptoms have resolved.
2. Review pain behavior management guidelines for parents. Revise as necessary. If indicated, implement formal reward/reinforcement program.
3. Review problem solving techniques.
4. Assist the patient and family in modifying familial or social contributors to pain.
5. Discuss high-risk situations and introduce notion of relapse prevention.
* Role play to prepare child and parents for difficult situations.
Note: Adapted from Boyle (1997); Campo & Fritz (2001); Cunningham & Banez (2006); Drossman (2006).
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