Nonspecific abdominal pain in pediatric primary care: evaluation and outcomes

Assessment of telemedicine versus in-person care in managing abdominal pain in children during the COVID-19 pandemic

OBJECTIVES

The COVID-19 pandemic has led to a dramatic increase in telemedicine care delivery. This raises the question of whether the visit type affects the care provided to patients in the pediatric gastroenterology clinic. The aim of this study is to assess whether diagnostic, treatment, and outcome measures differ between telemedicine and in-person visits in patients seen in pediatric gastroenterology clinics for the chief complaint of abdominal pain.

METHODS

We conducted a retrospective analysis of patients aged 0-22 who underwent their initial pediatric gastroenterology clinic visit, for abdominal pain, between March and September 2020 (n = 1769). The patients were divided into two groups: in-person or telemedicine. Clinical outcome measures were compared from the initial gastroenterology visit and followed for a total of 3 months.

RESULTS

There was an increase number of images (M = 0.52 vs. 0.36, p < 0.001), labs (M = 4.87 vs. 4.05; p = 0.001), medications (M = 2.24 vs. 1.67; p < 0.001), and referrals (M = 0.70 vs. 0.54; p < 0.001) performed per visit in the in-person group. Electronic communications (3.97 vs. 5.12 p <0.003) was less frequent after in-person visits. There was no difference in number of procedures (M = 0.128 vs. 0.122, p = 0.718), emergency room visits (M = 0.037 vs. 0.017 p = 0.61), follow-up visits (M = 1.21 vs. 1.21 p = 0.922), or telephone encounters (M = 1.21 vs. 1.12 p = 0.35) between the two groups.

CONCLUSION

Telemedicine utilizes less resources while having comparable outcome measurements in children with a chief complaint of abdominal pain.

[The prospect of using virtual reality technology in combination with psychotherapeutic methods in children with functional abdominalgia]

OBJECTIVE

The literature review addresses the effectiveness of psychotherapeutic methods in the treatment of functional abdominal pain syndrome and studying the prospects for using virtual reality technology in combination with psychotherapeutic methods according to the available literature.

MATERIAL AND METHODS

A search was conducted for available literature in the eLibrary and PubMed databases, published for the period 2017-2022, using the keywords: abdominalgia, psychotherapeutic methods, gut-brain axis, virtual reality technology.

RESULTS

Currently, the biopsychosocial concept of the etiopathogenesis of abdominal pain syndrome, which is not associated with an organic disease of the gastrointestinal tract, is used. A significant contribution to the formation of the disease is made by genetic, neuropsychological, neurophysiological factors, and disruption of the interaction of the gut-brain axis. Cognitive behavioral therapy, yoga, and hypnotherapy are applicable as effective psychotherapeutic methods in the complex treatment of abdominal pain syndrome in children. A promising direction is the use of virtual reality technology to increase the effectiveness of psychotherapeutic methods and reduce chronic abdominal pain syndrome by influencing the gut-brain axis. Practical research work devoted to this issue is currently rare.

CONCLUSION

In the complex treatment of functional abdominal pain syndrome in children, various psychotherapeutic methods are used, the most effective are cognitive behavioral therapy and hypnotherapy. It is necessary to stimulate domestic research work studying the joint use of virtual reality technology and psychotherapeutic methods in children aged 7 to 18 years.

Determining clinical predictors to identify non-specific abdominal pain and the added value of laboratory examinations: A prospective derivation study in a paediatric emergency department

AIM

To develop a model to discriminate non-specific abdominal pain (NSAP) from organic pain in the paediatric emergency department (PED) and evaluate the added value of laboratory markers.

METHODS

Prospective cohort study in an urban French PED including all patients aged ≥4 years with abdominal pain between November 2020 and May 2021. The outcome was the discrimination between NSAP (patients coded to have only "pain" or "constipation") and organic pain (all other diagnoses) using stepwise backward multivariate logistic regression method with bootstrap resampling.

RESULTS

The study enrolled 246 patients. Overall, 163 patients (66.2%) had NSAP. Four variables associated with organic pain: pain in the epigastric region (OR 0.48 [0.23-0.99]), worsening pain (0.57 [0.32-0.99]), pain migration (0.42 [0.17-0.99]) and vomiting (0.47 [0.26-0.84]) were integrated in a clinical model. To discriminate NSAP with a probability of 65%, model sensitivity was 71.8% (64.9-78.7), specificity was 53.0% (42.3-63.7), and the Net Benefit (NB) was 15.4%. White Blood Count and C-reactive protein results improved discriminative capacity of the model (AUC 0.708 [0.643-0.773] vs. 0.654 [0.585-0.723], p = 0.01) with a supplementary NB of 12%. Patient follow-up showed 95% diagnostic accuracy.

CONCLUSION

This study reveals a four-clinical predictor model with a NB of 15% in predicting NSAP. Validation studies are necessary.

Management of children with non-acute abdominal pain and diarrhea in Dutch primary care: a retrospective cohort study based on a routine primary care database (AHON)

OBJECTIVE

To describe the testing, prescription, referral, and follow-up management by general practitioners (GPs) for children presenting with non-acute abdominal pain and/or diarrhea in primary care.

DESIGN

Retrospective cohort study with one-year follow-up.

SETTING

Registry data from a Dutch primary care database (AHON) between 2015 and 2019.

SUBJECTS

Children aged 4-18 years old who presented by face-to-face consultation in primary care for non-acute abdominal pain and/or diarrhea (>7 days).

MAIN OUTCOME MEASURES

We recorded the proportions of children who received (1) diagnostic testing, medicine prescriptions, follow-up consultations, and referrals at their first visit and (2) repeat consultations and referrals by one-year of follow-up.

RESULTS

Among the 2200 children (median age, 10.5 years; interquartile range, 7.0-14.6) presenting to a GP with non-acute abdominal pain and/or diarrhea, most reported abdominal pain (78.7%). At the first visit, GPs performed diagnostic testing for 32.2%, provided a prescription to 34.5%, and referred 2.5% to secondary care. Twenty-five percent of the children had a follow-up consultation within four weeks and 20.8% had a repeat consultation between four weeks and one year. Thirteen percent of the children were referred to secondary care by one year. However, only 1% of all children had documentation of an organic diagnosis needing management in secondary care.

CONCLUSION

One-third of children received diagnostic testing or a medicine prescription. Few had a follow-up consultation and >10% was referred to pediatric care. Future research should explore the motivations of GPs why and which children receive diagnostic and medical interventions.

Twenty-year Outcomes of a Pediatric Chronic Abdominal Pain Cohort: Early Adulthood Health Status and Offspring Physical and Behavioral Health

Chronic abdominal pain (CAP) represents a common pediatric primary pain disorder that can have long-term effects on physical and mental health into adulthood. Pediatric CAP and Control cohorts recruited in childhood (∼11 years old, T1) and then assessed in emerging adulthood (∼20 years old, T2) were evaluated again for health outcomes in early adulthood (∼30 years old, T3) for the current study. Further, the study evaluated the mental and physical health of offspring of participants who had become parents. Participants who agreed to enroll at T3 (CAP: n = 90, Control: n = 55) completed measures regarding current health, health-related quality of life (HRQoL), and their child's health when applicable. Results indicated close to 20% of the CAP cohort reported recurrent CAP across all 3 timepoints. Participants with current CAP reported poorer HRQoL compared to participants with remitted CAP who reported poorer HRQoL compared to Control participants. The CAP cohort reported higher health-related anxiety compared to the Control cohort regardless of current pain status. CAP compared to Control participants reported greater emotional problems and fewer conduct problems in their children. Longitudinal studies are needed to assess the developmental course of pediatric chronic pain and intergenerational pathways of risk and resilience. Perspective: This article evaluates patterns of chronic abdominal pain from childhood into early adulthood. Patients with pediatric chronic abdominal pain continue to present with health-related anxiety in adulthood and report greater emotional problems in offspring.

Risk Factors for Recurrent Abdominal Pain in Children with Nonorganic Acute Abdominal Pain

PURPOSE

The purpose of this study was to identify the risk factors for recurrent abdominal pain (RAP) in children who presented with nonorganic acute abdominal pain.

METHODS

A retrospective, single study was conducted on 2-15-year-old children diagnosed with nonorganic acute abdominal pain at the pediatric outpatient department of Vajira Hospital, Nawamindradhiraj University, between January 2015 and December 2019. The potential risk factors were analyzed using univariate and multivariate analyses.

RESULTS

Of the 367 patients with nonorganic acute abdominal pain, 94 (25.6%) experienced RAP within three months. In this group with RAP, 76 patients (80.8%) were diagnosed with functional gastrointestinal disorders, including functional dyspepsia, irritable bowel syndrome, functional abdominal pain-not otherwise specified, and functional constipation. History of gastrointestinal infection (p=0.011), mental health problems (p=0.022), abdominal pain lasting ≥7 days (p<0.001), and change in stool frequency (p=0.001) were the independent risk factors associated with RAP in children with nonorganic acute abdominal pain; their odds ratios and 95% confidence intervals were 3.364 (1.314-8.162), 3.052 (1.172-7.949), 3.706 (1.847-7.435), and 2.649 (1.477-4.750), respectively.

CONCLUSION

RAP is a common problem among children who first present with nonorganic acute abdominal pain. The identification of risk factors may provide proper management, especially follow-up plans for this group in the future.

Primary care pediatricians' use of specialty referrals in treating children with chronic abdominal pain

Objectives Pediatric chronic abdominal pain (CAP) is typically managed in primary care settings, although specialty referrals may help patients access the full range of biopsychosocial treatment options. We investigated patterns of specialty referral (gastroenterology or mental health) among children with CAP seen in an academic pediatric primary care clinic. Methods We retrospectively identified patients age 4-17 years visiting our primary care clinic in 2016-2017 for abdominal pain, identified using International Classification of Diseases (ICD) codes. We excluded patients whose symptoms did not persist for 3 months or who were referred to a specialist before their symptoms had persisted for 3 months. Referral outcomes were assessed through December 2018. Results Of 320 patients with qualifying ICD codes, 253 were excluded because their symptoms did not persist for 3 months; 31 had already been referred to a specialist within 3 months of pain onset; and one chart could not be accessed. Of the remaining 34 patients (22/12 girls/boys, median age 10 years) 10 (29%) were referred to a gastroenterologist and none were referred to mental health specialists. No clinical or demographic factors reached statistically significant associations with gastroenterology referral, although pain duration was shorter among patients who were referred. Conclusions Children with CAP managed in our primary care clinic were seldom referred to specialists after their pain persisted over 3 months. Increasing focus on cognitive-behavioral therapies for chronic pain, and the low specialty referral rate, indicates that primary care practices should be prepared to offer these treatment modalities to children with CAP.

High Prevalence of Strongyloides among South Asian Migrants in Primary Care-Associations with Eosinophilia and Gastrointestinal Symptoms

Gastrointestinal (GI) symptoms are a frequent reason for primary care consultation, and common amongst patients with strongyloidiasis. We conducted a prospective cohort and nested case control study in East London to examine the predictive value of a raised eosinophil count or of GI symptoms, for Strongyloides infection in South Asian migrants. We included 503 patients in the final analyses and all underwent a standardised GI symptom questionnaire, eosinophil count and Strongyloides serology testing. Positive Strongyloides serology was found in 33.6% in the eosinophilia cohort against 12.5% in the phlebotomy controls, with adjusted odds ratio of 3.54 (95% CI 1.88-6.67). In the GI symptoms cohort, 16.4% were seropositive but this was not significantly different compared with controls, nor were there associations between particular symptoms and Strongyloidiasis. Almost a third (35/115) of patients with a positive Strongyloides serology did not have eosinophilia at time of testing. Median eosinophil count declined post-treatment from 0.5 cells × 109/L (IQR 0.3-0.7) to 0.3 (0.1-0.5), p < 0.001. We conclude Strongyloides infection is common in this setting, and the true symptom burden remains unclear. Availability of ivermectin in primary care would improve access to treatment. Further work should clarify cost-effectiveness of screening strategies for Strongyloides infection in UK migrant populations.

Undifferentiated Abdominal Pain in Children Presenting to the Pediatric Emergency Department

Although common, little is known about the characteristics and management of undifferentiated abdominal pain (UAP) in the pediatric emergency department (ED). This study was a 12-month retrospective study for "abdominal pain" ED visits. Patients without an identifiable diagnosis were categorized as "UAP," while others with identified disease processes were categorized as "structural gastrointestinal diagnosis (SGID)." We included 2383 (72%) visits with 869 (36.5%) UAP visits and 1514 (63.5%) SGID visits. SGID patients had more laboratory tests (811 [53.6%] vs 422 [48.6%], P = .0186), and often had multiple tests performed (565 [69.7%] vs 264 [62.6%], P = .0116). Computed tomography and ultrasound scans were more common in SGID (computed tomography: 108 [7.1%] vs 27 [3.1%], P = .0004; ultrasound: 377 [24.9%] vs 172 [19.9%], P = .0044), and laboratory results (white blood cell count, hemoglobin, albumin, C-reactive protein) were abnormal at significantly higher rates. Analyses revealed the duration of pain as primary covariate in variance of pain etiology. Clinical features, such as duration of pain, may be augmented by laboratory tests to facilitate recognition of UAP in the ED.

Abdominal pain is a common and recurring problem in paediatric emergency departments

AIM

Abdominal pain is a frequent reason for paediatric emergency department visits, but specific research is lacking. Our aim was to obtain information on the diagnosis of abdominal pain and what healthcare services children with this condition need.

METHODS

This retrospective study focused on patients visiting the emergency department of the Children's Hospital Iceland in 2010 with abdominal pain and any subsequent visits up to 1 January 2015.

RESULTS

There were 11 340 visits to the emergency department in 2010 and 1118 children made 1414 (12%) visits due to abdominal pain. The majority (58%) with abdominal pain were girls (p < 0.001) and they were older than the boys, with an average age of 12 versus 10 years (p < 0.001). The most common diagnoses were non-specific abdominal pain (40%), constipation (22%) and viral infections (13%). During the follow-up period, 423/1118 children (38%) visited the emergency department 883 times, 58% were girls and the most common diagnosis was non-specific abdominal pain (37%). Of the 436 children initially diagnosed with non-specific abdominal pain, 154 (35%) revisited the emergency department during the follow-up period.

CONCLUSION

Abdominal pain was a common reason for visits to the paediatric emergency room and a third paid more than one visit.

Emergency Provider Use of Plain Radiographs in the Evaluation of Pediatric Constipation

BACKGROUND

More than half of children evaluated as outpatients for abdominal pain are diagnosed with constipation. X-ray use in this scenario is variable: less than 5% in clinic settings, greater than 70% in emergency departments. X-rays increase misdiagnosis rate, remain costly, and involve radiation exposure.

OBJECTIVES

The aim of this study was to assess the use of plain radiographs by pediatric emergency medicine (PEM) providers in the diagnostic evaluation and management of pediatric constipation.

METHODS

A cross-sectional survey of PEM providers was performed. Survey participants were subscribers to the American Academy of Pediatrics Section on Emergency Medicine Listserv. To assess diagnostic and therapeutic approaches, participants were presented a case of pediatric constipation meeting Rome III clinical criteria. Participants also categorized frequency of x-ray use, reasons for obtaining, estimated diagnostic utility, and elements of institutional standard approach. Descriptive statistical analyses were performed.

RESULTS

Three hundred five of 1272 Listserv members (24%) responded. Ninety-nine percent elected to treat for constipation in a case meeting Rome III clinical criteria; one third (31%) would obtain plain radiographs for this same scenario. Plain radiographs were viewed as somewhat (59%) or minimally (29%) value-added in the evaluation of suspected pediatric constipation. Obtaining family buy-in (44%) was the most common reason for utilizing plain radiographs. Frequency of use varied across geographic regions and with participant and hospital characteristics.

CONCLUSIONS

This survey suggests that many PEM providers obtain radiographs to convince families of the diagnosis of constipation. This is not a viable management plan given the risks of radiation as well as costs. There remains room for improvement as we attempt to reduce use of radiation in the evaluation of common pediatric illnesses.

Relationship between Pain, Somatisation, and Emotional Awareness in Primary School Children

Poor emotional awareness (EA) seems to play an important role in the aetiology of functional somatic complaints featuring pain as a form of somatisation. The aim of this study was to shed more light on this relationship by investigating the links between pain, somatisation, and emotional awareness in a nonclinical population of 445 children aged 6–10. Assessing pain through the Children's Somatisation Inventory (CSI), a very high percentage of the entire sample complained of experiencing pain at least one site (84.07%) over the preceding 2 weeks. Although no difference in the prevalence of pain (whole) was found when the sample was subdivided by Levels of Emotional Awareness Scale-Children (LEAS-C), a relationship between low level of LEAS-Self and prevalence of headache (H) was detected (χ2=7.69, p=0.02). LEAS (Self) was correlated with the intensity of back pain (BP) (r=-0.12; p< 0.05), H (r=-0.12; p< 0.05) but not with abdominal pain (AP). Pain worsened QoL, and the greatest negative correlation with total KidScreen-10 was found for abdominal pain (r=-0.14; p< 0.01). Our results suggest that low EA is a predictor of somatisation, BP severity, H, and severity of pain in general, but not AP.

Treatment of Functional Abdominal Pain With Antidepressants: Benefits, Adverse Effects, and the Gastroenterologist's Role

OBJECTIVES

Pediatric functional abdominal pain is often treated with tricyclic antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs). The aim is investigating antidepressant use for treatment efficacy, correlation of response to psychiatric factors, and impact of adverse effects in regard to physicians' prescribing patterns.

METHODS

Retrospective review (2005-2013) children (5-21 years old) with functional abdominal pain treated with SSRI or TCA. Of the 531 cases with functional abdominal pain, 192 initiated SSRIs or TCAs while followed by gastroenterology. Charts reviewed for symptoms, adverse effects, and response: decreased pain or increased daily functioning.

RESULTS

Sixty-three of 84 (75%) SSRI patients improved, 56 of 92 (61%) TCA patients improved (P = 0.03). Logistic regression controlling for psychiatric factors: SSRI remained significant over TCA (P = 0.04). Thirty-two of 67 (48%) patients with constipation received TCAs and 26 of 45 (58%) patients with diarrhea received SSRIs (P = 0.64). Three SSRI patients reported gastrointestinal effects, all diarrheal-type symptoms, and 2 TCA patients reported gastrointestinal effects, both constipation, in all it led to discontinuation. Thirteen (29%) of diarrheal-type patients reported adverse effects causing discontinuation as compared to 7 (8%) in the constipation group (P = .01). Twenty-one (25%) SSRI patients reported adverse effects with 5 (6%) mood disturbances. Twenty (22%) TCA patients reported adverse effects, 13 (14%) with mood disturbances (P = .07). Overall, 12 (14%) SSRI patients discontinued medication due to adverse effects, whereas 16 (17%) TCA patients (P = 0.24) did.

CONCLUSIONS

Patients had significantly greater response to SSRIs than TCAs, remaining significant after controlling for psychiatric factors. Little significance is given to patient's associated gastrointestinal symptoms, frequently resulting in adverse effects and termination of medication.

Mind Over Gut: Psychosocial Management of Pediatric Functional Abdominal Pain

INTRODUCTION

Functional abdominal pain (FAP) refers to a common set of symptoms that characterizes abdominal pain for which there is no identifiable organic disease process. FAP is associated with functional disability, but understanding of its pathogenesis is incomplete. The condition appears to stem from an interaction between physical and psychological mechanisms.

METHOD

A literature search was conducted to explore the psychosocial management of FAP and the role of nurse practitioners in treatment.

RESULTS

A growing body of evidence supports the efficacy of psychosocial interventions, including cognitive behavioral therapy, hypnotherapy, and multidisciplinary treatment programs. There are no randomized controlled trials at the primary care level to guide management.

DISCUSSION

Nurse practitioners can provide the supportive and consistent patient-provider relationship that is integral to the management and treatment of FAP. More research is necessary to understand how best to incorporate behavioral interventions into primary care practice.

Current concepts in functional gastrointestinal disorders

PURPOSE OF REVIEW

Functional gastrointestinal disorders (FGIDs) are some of the most common and challenging disorders in pediatrics. Recurrent abdominal pain is the central feature of pain-associated FGIDs such as irritable bowel syndrome. A thorough understanding of current pathophysiological concepts is essential to successful management.

RECENT FINDINGS

The brain-gut axis, role of microbiota and the biopsychosocial model are emerging concepts in FGIDs. The biopsychosocial model focuses on the interplay between genes, environment, and physical and psychosocial factors. Interactions between microbiota and the central, enteric and autonomic nervous systems form the link between gut functions and conscious perceptions. Irritable bowel syndrome is the most extensively studied and prototypical pain-associated FGIDs. An aberrant processing of pain or physiologic signals originating from the gut causes a state of visceral hypersensitivity - a central mechanism of functional pain. Psychosocial and autonomic influences also play large roles. Therapy is tailored to the individual patient and comorbid symptoms.

SUMMARY

This review highlights the complex mechanisms and the aberrant brain-gut neural connections forming the basis of FGIDs. Successful management of FGIDs requires knowledge of the underlying pathophysiology coupled with a multidisciplinary treatment approach. Management should focus on cognitive behavioral therapy, dietary factors along with gastrointestinal motility and psychotropic drug therapy.