Management of recurrent abdominal pain

Brief telephone-delivered cognitive behavioral therapy targeted to parents of children with functional abdominal pain: a randomized controlled trial

Pediatric functional abdominal pain disorders (FAPDs) are associated with increased health care utilization, school absences, and poor quality of life (QoL). Cost-effective and accessible interventions are needed. This multisite study tested the effects of a 3-session cognitive behavioral intervention delivered to parents, in-person or remotely, on the primary outcome of pain severity and secondary outcomes (process measures) of parental solicitousness, pain beliefs, catastrophizing, and child-reported coping. Additional outcomes hypothesized a priori and assessed included functional disability, QoL, pain behavior, school absences, health care utilization, and gastrointestinal symptoms. The study was prospective and longitudinal (baseline and 3 and 6 months' follow-up) with 3 randomized conditions: social learning and cognitive behavioral therapy in-person (SLCBT) or by phone (SLCBT-R) and education and support condition by phone (ES-R). Participants were children aged 7 to 12 years with FAPD and their parents (N = 316 dyads). Although no significant treatment effect for pain severity was found, the SLCBT groups showed significantly greater improvements compared with controls on process measures of parental solicitousness, pain beliefs, and catastrophizing, and additional outcomes of parent-reported functional disability, pain behaviors, child health care visits for abdominal pain, and (remote condition only) QoL and missed school days. No effects were found for parent and child-reported gastrointestinal symptoms, or child-reported QoL or coping. These findings suggest that for children with FAPD, a brief phone SLCBT for parents can be similarly effective as in-person SLCBT in changing parent responses and improving outcomes, if not reported pain and symptom report, compared with a control condition.

Cognitive Behavior Therapy for the Treatment of Recurrent Abdominal Pain

This article outlines the rationale and use of cognitive behavior therapy in the treatment of the gastrointestinal symptoms and illness behavior associated with Recurrent Abdominal Pain (RAP), often described as the childhood variant of IBS. It begins with a conceptualization of the social learning perspective of RAP, and then covers the relationship between childhood social learning and adult and childhood illness behavior. Studies that have utilized a cognitive behavior therapy approach for treating adult pain are summarized. Finally, specific cognitive behavior therapy trials for treating RAP, as well as moderators of treatment effectiveness, are discussed.

Plumbism--a mimicker of common childhood symptoms

Lead poisoning is a preventable entity that can affect almost every system of the body. Its toxic effects range from subtle common childhood symptoms to even death. In a prospective study forty six children with at least one symptom compatible with plumbism were enrolled after screening patients attending medical services at AIIMS. The work-up included a detailed clinical history and examination including intelligence quotient (IQ) and behaviour. Blood lead levels were estimated in all with due precautions. Their ages ranged from 2.5 to 18 years and M:F ratio was 2:1. The common symptoms included unexplained recurrent colic (39), anorexia (21), sporadic vomiting and constipation (13), pigmented gum lines (11), growth failure (11), history of pica (9) etc. None of the children had acceptable blood lead levels (< 10 micrograms/dl). Ninety three per cent children had levels > 20 micrograms/dl and 47.8% had > 45 micrograms/dl. Statistically significant correlation with blood lead levels was seen with most symptoms. Plumbism can mimic common childhood illnesses and should be investigated in children with a clinically compatible profile. Community awareness with regard to pica reduction may be an important preventive measure. This silent epidemic needs to be aggressively tackled by a multipronged approach.

Impaired accommodation of the proximal stomach in children with recurrent abdominal pain

BACKGROUND

A new ultrasonographic method was applied in children with recurrent abdominal pain, to study accommodation of the proximal stomach to a meal.

METHODS

After an overnight fast, 20 patients with recurrent abdominal pain (age, 7-14 years) and 23 healthy control subjects (age, 7-13 years), were scanned by a 5-MHz transducer positioned in the epigastrium, to monitor the size of the proximal stomach before and after a test meal of meat soup.

RESULTS

Children with recurrent abdominal pain had a significantly smaller sagittal area of the proximal stomach at 10 and 20 minutes after the meal than in healthy control subjects (P = 0.01 for both) and significantly higher emptying fraction of the proximal stomach at 10 minutes after the meal than in healthy control subjects (P = 0.02). There was no significant difference in emptying of the distal stomach between the patients and healthy control subjects. Children with recurrent abdominal pain experienced more symptoms (pain, bloating) in response to the test meal than did healthy control subjects.

CONCLUSION

The results support the view that recurrent abdominal pain in children may be a motility disorder that can be detected in the proximal stomach as an impairment of adaptive relaxation in response to a meal. This new ultrasonographic method may become a valuable diagnostic tool in patients with recurrent abdominal pain.

One-week treatment with omeprazole, clarithromycin, and metronidazole in children with Helicobacter pylori infection

BACKGROUND

The efficacy of a 1-week "triple therapy" in children with Helicobacter pylori gastritis and recurrent abdominal pain was studied. The effect of treatment was also studied in correlation to recurrent abdominal pain.

METHODS

Thirty-two children with recurrent abdominal pain were investigated with H. pylori serology, 13C-urea breath test, and endoscopy. Gastric biopsy specimens were analyzed with a rapid urease test and histopathology. H. pylori-positive children were treated with omeprazole, clarithromycin, and metronidazole for 7 days. The same treatment was repeated for 2 weeks if a urea breath test produced positive results 1 month after the treatment period. If the test results were still positive after treatment, a second endoscopy was performed with culture.

RESULTS

Twenty-eight (87.5%) children were urea breath test-negative at follow-up 4 weeks (range, 4-15) after treatment. Another child became H. pylori-negative after a second treatment course. Two of the three children who were still positive after the two treatment periods, showed resistance to metronidazole and clarithromycin.

CONCLUSIONS

One-week therapy with omeprazole, clarithromycin and metronidazole is an effective treatment in children with H. pylori infection. Bacterial resistance to clarithromycin and metronidazole must be monitored if treatment fails.

Somatoform disorders in children and adolescents: a review of the past 10 years

OBJECTIVE

To review the literature on somatoform disorders in children and adolescents relevant to recertification by the American Board of Psychiatry and Neurology.

METHOD

The psychiatric, pediatric, and psychological literatures were searched for clinical or research articles in the past 10 years dealing with somatization and somatoform disorders.

RESULTS

Somatizing presentations are organized conceptually; somatization disorder, body dysmorphic disorder, hypochondriasis, conversion disorder, vocal cord dysfunction, pain disorder, and recurrent abdominal pain are described in children and adolescents; empirical evidence for treatment efficacy is scant, but clinically reasonable approaches are applied.

CONCLUSION

More developmentally appropriate diagnostic schemas and better outcome studies are needed in all the somatoform disorders for children and adolescents.

Sucrose permeability in children with gastric damage and Helicobacter pylori infection

BACKGROUND

Increased permeability to sucrose has been recently shown to be a good marker of gastric mucosal damage in adults.

METHODS

This test was evaluated in 40 children consulting for recurrent abdominal pain and the results were correlated with endoscopic and histologic findings and with the presence of H. pylori.

RESULTS

The gastric mucosa was considered endoscopically normal in 31 children; 3 had duodenitis and 6 had mild gastritis. Abnormal endoscopic findings were associated with increased urinary sucrose excretion (MANOVA F = 7.30; p = 0.002). In the 6 children with mild gastritis, mean sucrose excretion was twice that of controls (0.060 +/- 0.024 vs. 0.029 +/- 0.018, respectively; p = 0.019) and significantly higher than the group with duodenitis (0.037 +/- 0.013; p = 0.038). The specificity and sensitivity of sucrose permeability test for detection of gastric damage were 90.3% and 83.3%, respectively. H. pylori was detected in 62.5% of children including all patients with mild gastritis, in 2 out of 3 with duodenitis and 17 out of 31 endoscopically normal controls. No differences in sucrose excretion were observed in relation with the presence of H. pylori or histological findings in the control group.

CONCLUSIONS

Urinary sucrose excretion is a good marker of mucosal gastric damage in children and may be used as a screening test in large groups of populations.

Abdominal pain in cystic fibrosis

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