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Reged: 12/09/02
Posts: 7655
Loc: Seattle, WA
New Recommendations for Treating Children With Chronic Abdominal Pain
      03/28/05 01:59 PM

New Recommendations for Treating Children With Chronic Abdominal Pain

News Author: Laurie Barclay, MD
CME Author: Désirée Lie, MD, MSEd

March 4, 2005 — A subcommittee on Chronic Abdominal Pain of the American Academy of Pediatrics (AAP) and the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition have generated a clinical report to provide guidance to clinicians treating children with this condition. The clinical report and an accompanying technical report are published in the March issue of Pediatrics.

"Children and adolescents with chronic abdominal pain pose unique challenges to their caregivers," write Richard B. Colletti, MD, and colleagues from the Subcommittee on Chronic Abdominal Pain. "Affected children and their families experience distress and anxiety that can interfere with their ability to perform regular daily activities. Although chronic abdominal pain in children is usually attributable to a functional disorder rather than organic disease, numerous misconceptions, insufficient knowledge among health care professionals, and inadequate application of knowledge may contribute to a lack of effective management."

Recommendations in the clinical report are based on the evidence reviewed in the technical report and on consensus opinion of the subcommittee members. However, the subcommittee acknowledges that the recommendations do not indicate an exclusive course of treatment or serve as a standard of medical care and that variations based on individual circumstances may be appropriate.

Although the classic definition of chronic abdominal pain used during the last four decades has used the criterion of at least three pain episodes for at least three months interfering with function, the authors suggest that in clinical practice, pain that exceeds one or two months in duration can be considered chronic.

Specific recommendations are as follows:

The term "recurrent abdominal pain" should no longer be used. Functional abdominal pain, the most common cause of chronic abdominal pain, is a specific diagnosis distinct from anatomic, infectious, inflammatory, or metabolic causes of abdominal pain. Specific categories may include functional dyspepsia, irritable bowel syndrome, abdominal migraine, or functional abdominal pain syndrome.

Without needing additional diagnostic testing, the primary care clinician can generally diagnose functional abdominal pain correctly in children four to 18 years of age with chronic abdominal pain, provided there are no alarm symptoms or signs, the physical examination is normal, and stools are negative for occult blood.

Alarm symptoms prompting additional diagnostic testing may include involuntary weight loss, linear growth deceleration, gastrointestinal tract blood loss, significant vomiting, chronic severe diarrhea, persistent right-upper or right-lower quadrant pain, unexplained fever, family history of inflammatory bowel disease, or abnormal or unexplained physical findings. Alarm signs may include localized right-upper or right-lower quadrant tenderness, localized fullness or mass effect, hepatomegaly, splenomegaly, costovertebral angle tenderness, spine tenderness, and perianal abnormalities.

If pain significantly decreases quality of life, testing may also be indicated to reassure the patient, parent, and physician of the absence of organic disease.

Psychological factors should be addressed in diagnostic evaluation and management, even though they may not help distinguish between organic and functional pain.

Family education is an important part of management of functional abdominal pain, using simple language to explain that the pain is real, but that there is most likely no underlying serious or chronic disease.

Reasonable treatment goals should be established, aimed at return to normal function and to school rather than the complete disappearance of pain.

Medications for functional abdominal pain "are best prescribed judiciously as part of a multifaceted, individualized approach to relieve symptoms and disability." Time-limited use of medications, such as acid-reduction therapy, antispasmodic agents, smooth muscle relaxants, low doses of psychotropic agents, or nonstimulating laxatives or antidiarrheals may be appropriate to decrease symptom frequency or severity.

Additional research is needed to advance still limited knowledge on chronic abdominal pain in children. The authors recommend detailed description of symptoms, eligibility criteria, work-up, and findings; use of validated outcome measures; evaluation of potential differences in course and treatment in subgroups of patients with different symptom phenotypes; research in diverse populations; and validation of the Rome II criteria in a range of clinical settings and populations.
"In view of the paucity of published literature on therapeutic approaches to this condition, there is an urgent need for trials of all currently used interventions in children with functional abdominal pain," the authors conclude.

The current authors also support the statements of the Functional Bowel Disorders Working Group Report of the First World Congress of Pediatric Gastroenterology, Hepatology, and Nutrition meeting that "there is a need to develop drugs to modulate abnormalities in sensorimotor function of the enteric nervous system in functional disorders to relieve specific symptoms and to assess the proper role of these drugs in the treatment of children and adolescents," and that "the role of antidepressants (tricyclics, selective serotonin reuptake inhibitors) in the treatment of functional gastrointestinal disorders associated with abdominal pain needs to be assessed."

Pediatrics. 2005;115:812-815, e370-e381

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