Irritable Bowel Syndrome Message Boards | 11 year old daughter been in pain every night for a year!

I had severe IBS when I was ten and it was pain predominate and effected me all the time.

Here is some info for you.

However, there are things you can do.

I am posting some really good resources and information here for you.

This is information from the International Foundation for Functional Gastrointestinal Disorders. On there website kidsgihealth.

This here is really good information.

Questions and Answers

http://www.aboutkidsgi.org/questionsandanswers.html

and

NEW YORK (Reuters Health) - Childhood abdominal pain is a common complaint, and it may progress to adult irritable bowel syndrome (IBS) in some cases, according to a study in the American Journal of Gastroenterology.

IBS is marked by bloating, pain, constipation and diarrhea, and often doesn't seem to have a direct physical cause -- although the symptoms are certainly real.

"The natural history of childhood abdominal pain and its association with adult IBS remain poorly described," Dr. Nicholas J. Talley, of the Mayo Clinic College of Medicine, Rochester, Minnesota, and colleagues note in their report.

To investigate, they assessed the characteristics of childhood abdominal pain over the first 11 years of life in some 1,000 children born in Dunedin, New Zealand in 1972, and examined the association of childhood abdominal pain with IBS at when the participants reached 26 years of age.

A history of abdominal pain was documented in 18 percent of the children.

Childhood abdominal pain was more common in females than in males. The prevalence of abdominal pain peaked at age 7 to 9 years among boys, but it remained stable across assessments for females.

IBS at age 26 years was about 2 or 3 times more common among subjects with a history of childhood abdominal pain between the ages of 7 and 9 years compared to those with no history.

Factoring in gender, socioeconomic status, psychiatric disorder at age 26, childhood emotional distress, or maternal malaise did not alter this association.

"The emergence of multiple stressors in the home and school environment may present a plausible mechanism to account for these findings," Talley's team suggests.

As they point out, "The 7 to 9 year age-period follows closely from the school starting age in many cultures, and children who are predisposed to stress-related disorders may be at particular risk of developing symptomatic complaints at this point."

SOURCE: American Journal of Gastroenterology, September 2005.

and
webmd
Mind-Body Technique Eases Kids' Gut Pain

Kids Have Fewer Days of Abdominal Pain When Using Relaxation Technique

http://www.webmd.com/content/article/72/81542.htm

FYI

Defecation Anxiety Linked to Functional Constipation in Children

Charlene Laino

Oct. 15, 2003 (Baltimore) � Children with functional constipation have significantly more anxiety related to toileting behavior than healthy children � anxiety. This anxiety makes them more likely to continue to suffer from the problem, a prospective study suggests.

Moreover, some of these children develop generalized anxiety, reported researchers from the Cleveland Clinic Foundation.

"Constipated kids were not generally anxious overall, but among those with defecation anxiety we saw an increase in general anxiety," said Gerard Banez, PhD, a child psychologist at the Cleveland Clinic Foundation. "This does not prove cause-and-effect, but does suggest that those constipated children with greater defecation anxiety also exhibit increased general anxiety."

Painful bowel movements can make a child fearful of pain, Dr. Banez said. That fear can be generalized to sitting on the toilet.

The research was described here today at the American College of Gastroenterology 68th annual scientific meeting.

Up to 7.5% of children suffer from constipation, which accounts for about 3% of visits to pediatricians and up to 25% of visits to pediatric gastroenterologists, according to data cited in the study.

According to the researchers, constipation carries a host of physical and psychological consequences, and defecation anxiety is often implicated as a primary contributor to constipation.

Dr. Banez and colleagues studied 98 boys and girls aged 6 to 18 years who suffered from functional constipation. The youngsters completed the Defecation Anxiety Scale�Self-Report and Revised Children's Manifest Anxiety Scale, which measures generalized anxiety. The parents also rated their children's defecation anxiety on the Defecation Anxiety Scale�Parent Rating Scales.

By both self-report and parent report, children with functional constipation were found to have significantly more defecation anxiety than healthy children or children with asthma, the researchers said.

Overall, 70% of the children reported defecation anxiety compared with 58% of a control group of healthy children and 65% of children with asthma. The parents reported that 82% of their children suffered from defecation anxiety.

In addition, 30% of the children with constipation reported generalized anxiety. The greater the defecation anxiety, the greater the generalized anxiety, Dr. Banez said. Children with defecation anxiety have a higher chance of having generalized anxiety, although some children with no significant generalized anxiety still had defecation anxiety, he added.

Physicians who see children with constipation anxiety should rule out any medical cause, Dr. Banez said. Also, consider defecation anxiety in the differential diagnosis of any child whose parents report that their child seems to be withholding stool, is tearful at the urge to use the toilet, or shows vigorous resistance to using the toilet, he said.

Also, physicians should discuss strategies that promote relaxed toilet sitting as well as suggest dietary changes � possibly with a stool softener thrown in � to promote softer stools, Dr. Banez said.

William Whitehead, MD, professor of medicine at the University of North Carolina in Chapel Hill, said he has had some luck treating constipation anxiety with biofeedback, although he said that studies in Europe suggest that laxatives work just as well as the relaxation technique.

The question now, he said, is whether anxiety is the cause or the consequence of constipation. ?This study doesn?t really tell us, but it is still a major advance, the first trial I know of where they have linked defecation and anxiety directly using such a systematic approach.?

ACG 68th Annual Scientific Meeting: Abstract 723. Presented Oct. 15, 2003.

Reviewed by Gary D. Vogin, MD

Kids Take Sickness Cue From Parents
Excerpt By Nancy A. Melville, HealthScoutNews

(HealthScoutNews) -- The behavioral patterns of those with irritable bowel syndrome (IBS) can color their children's experiences of their own illnesses.

http://preventdisease.com/news/articles/kids_sickness_parents.shtml

Childhood bellyaches can be gut-wrenching
Agony but no answers: Youngsters sometimes endure months of unsuccessful tests, bouncing from doctor to doctor
See BELLYACHES, D2

Bellyaches often defy easy cures
By Laurie Tarkan
The New York Times

Color illustration by Earl F. Lam III

When 12-year-old Hannah Scott began middle school last year, she was so nervous that her stomach was not just in knots, it was in serious pain.
''It would start in the morning when I'd leave the house,'' said Hannah, a wisp of a girl with light brown freckles and long sandy hair. ''And when I got to school, it was really, really bad. I'd go to the nurse every other day, and be sent home.''
When the bellyaches persisted for months, Hannah's parents took her to a pediatric gastroenterologist, who ordered tests, including X-rays, a colonoscopy and an endoscopy, to rule out serious problems.
After nothing showed up, the ailment was diagnosed as irritable bowel syndrome, a gastrointestinal disorder with no organic cause and no proven treatment in children. But the doctor said there was nothing to do about it; eventually, it got so bad that her parents pulled her out of school.
An estimated 10 percent to 20 percent of all school-age children suffer severe recurrent abdominal pain. But many children and adolescents go for 13 to 18 months before being treated, and some are never treated at all.
In some cases, untreated pain is so debilitating that they miss school, dance classes, sports activities and social events. They are at risk of falling behind academically, physically, socially and developmentally.
Experts say that organic causes like ulcers, inflammation or intestinal blockages are to blame in only a small minority of children, 5 percent to 10 percent.
A majority suffer instead from what are called functional gastrointestinal disorders. The most common are functional abdominal pain, in which pain is the only symptom; irritable bowel syndrome, which brings on pain along with diarrhea or constipation; and functional dyspepsia, which typically shows up as pain with nausea or a feeling of fullness.
Often, children who have recurrent abdominal pain are put through a battery of invasive tests. They are placed on restrictive diets and given large doses of acid-suppressing medications or anti-diarrhea drugs, which may offer some relief for the symptoms, but often do nothing for pain.
Some children are told that their illness is ''all in their head,'' or that they are faking it.
''There are a lot of misconceptions that make the life of these children more difficult,'' said Carlo Di Lorenzo, chief of pediatric gastroenterology at Children's Hospital of Columbus, Ohio.
''They bounce from doctor to doctor, get more and more tests, until things get better or they find a specialist who knows how to treat them,'' Di Lorenzo said. In fact, there are clear criteria for diagnosing disorders that cause recurrent abdominal pain, and for most children, the diagnosis can be made without invasive tests.

Brain and gut: New approaches to treating pain are already being used in adults, including cognitive behavioral therapy; alternative treatments like relaxation techniques and massage therapy; and antidepressants. But they have not been widely adopted for children, in part because only a handful of small studies support such use.
In recent years, however, experts have begun to understand more about the connections between the brain and the gut, a relationship that is reflected in popular expressions like ''a gut-wrenching experience'' or ''having butterflies in your stomach.''
The gastrointestinal tract is awash in nerve cells and neurotransmitters. About 95 percent of the body's neurotransmitter serotonin is in the intestinal tract. Stress, nervousness, fear and other emotions often play out their own drama in the gut. In children with abdominal pain, the intestinal tract becomes hypersensitive to stimuli, with the slightest bit of gas, for instance, sending a flood of pain signals to the brain.
The problem appears to be a mismatch in signaling between the brain and the gut, said Lonnie Zeltzer, director of the Pediatric Pain Program at the David Geffen School of Medicine at the University of California, Los Angeles. ''If you have ongoing pain, you can develop abnormal pain pathways, so that the volume of pain signaling

is being turned up and up,'' Zeltzer said.
What causes the hypersensitivity is not completely understood, but experts believe that it is often set off by a stomach virus or an infection.
''It's not uncommon that a family will get viral gastroenteritis, the whole family gets better except the child,'' said Zeltzer, author of Conquering Your Child's Chronic Pain: A Pediatrician's Guide for Reclaiming a Normal Childhood. ''The pain system is turned on and stays on.''
Experts do not know why some children and adolescents develop this problem and others do not. One clue may be that children with abdominal pain tend to be unusually worried and anxious.
As an understanding of the brain-gut connection grows, however, some centers have begun to use techniques like cognitive behavioral therapy, relaxation training, massage therapy and other alternative approaches as a first line of treatment.
The effectiveness of these therapies is still debated, and the number of studies examining their effectiveness in children is very small, experts say. In one study published in the August issue of The Journal of Pediatric Gastroenterology and Nutrition, 18 children ages 8 through 17 who had pain for about a year were taught guided imagery and progressive relaxation.
In four to seven sessions, 89 percent of the children reported a reduction in pain, to an average of two episodes a week, from six, said Nader N. Youssef, a pediatric gastroenterologist at the Goryeb Children's Hospital in Morristown, N.J. and the lead author of the study. The children had fewer missed school days, and their quality-of-life scores rose significantly.

Tests can be stressful: Another novel approach is the use of antidepressants for the pain. An analysis of large studies of adults with functional abdominal pain found evidence for the effectiveness of low doses of tricyclic antidepressants, though the drugs have not been studied in children for such complaints.
Tricyclics, an older class of antidepressants, have also been associated with rare cases of unexplained sudden death, and some doctors require an electrocardiogram before prescribing them to children.
For those parents trying to help children cope with recurrent bellyaches, experts say it is important to understand that there does not have to be an organic reason for the pain, Zeltzer said. She advised parents to avoid unnecessary tests, because the tests themselves are stressful.
She and other experts recommend that parents help children learn relaxation techniques like breathing methods, progressive muscle relaxation or visualization to use when they are feeling stressed. The techniques are explained on many Web sites.
Children with recurrent stomach pain, experts say, should be kept in school and should stay involved in activities, if possible. These distractions help take the focus off the pain. Good sleep habits and exercise also help reduce pain.
In Hannah's case, her mother took her to a pain management center in Kansas City, Mo., where she learned cognitive behavioral strategies to help change her reactions to stress and relaxation exercises to reduce the stress and pain.
By late March, Hannah was back in school. ''I think I stopped thinking about it and worrying about it,'' she said.

http://www.sltrib.com/healthscience/ci_2546772;jsessionid=KDPSAI1MCRB1ECUUCBQSFEY

KidsHealth.org Gastrointestinal Problems

KidsHealth.org Gastrointestinal Problems
--------------------------------------------------------------------------------
FYI

"Gastrointestinal Problems

Sun Dec 5, 7:00 PM ET

KidsHealth.org

Yahoo! Health
Have questions about your health?
Find answers here.

"I can go by myself now." You proudly celebrated the day when your toddler began to make toilet trips alone. But now you need to guide him through a childhood that's bound to have a tummy ache or two. How do you know what's normal?

Many parents expect their child to pass one bowel movement (stool) each day, and they begin to worry if this doesn't happen. But a daily bowel movement isn't necessarily "normal" for every child, and your child may have anywhere from three bowel movements a day to three a week and still be OK. The key here is to check for signs of pain, cramps, bloating, or fullness in the abdomen. Stools should be soft and easy to pass - neither too watery nor too dry and hard. And if your child sees blood with a bowel movement, either in the toilet water or on a toilet tissue, you should always call your child's doctor.

Constipation
Common adult bowel problems can affect children, too. For example, constipation can trouble children who eat a typical fast food diet - rich in fats (burgers, fries, milkshakes) and processed sugars (candy, cookies, sugary soft drinks). These children may have bowel movements that are hard, dry, and painful. Their time between bowel movements may be 4 days or more.

If constipation is a problem for your child, you might first take a serious look at his diet - does it include enough water and enough dietary fiber? Check for good exercise habits, since physical activity nudges the bowels into action. Also, setting a regular meal schedule can help some children develop regular bowel habits, since eating is another natural stimulant for bowel activity. If necessary, schedule breakfast a little earlier to give your child a chance for a relaxed visit to the bathroom before school.

Some children become constipated because they ignore the natural urge to empty their bowels. They may not want to use a restroom away from home, or they may feel embarrassed to ask a teacher to be excused from class. When this happens, simple reassurance from you and your child's teacher may be the only treatment necessary.

Most childhood constipation problems can be helped by sensible changes in lifestyle or diet. Laxatives are not usually needed. In fact, using laxatives unnecessarily can actually cause constipation. So always ask your child's doctor before giving your child any medicine for irregularity. Rarely, constipation can be a sign of other medical illnesses, so keep your child's doctor informed if your child continues to have problems.

Irritable Bowel Syndrome
In adults, irritable bowel syndrome (IBS) is responsible for almost as many work absences as the common cold. IBS can affect children, too, giving them a puzzling set of digestive complaints. Sometimes it's cramps, gas, and diarrhea; sometimes it's bloating and constipation; and sometimes it's alternating bouts of both. Children with IBS may sometimes pass mucus with their bowel movements, but they have no rectal bleeding or fever.

IBS often troubles children during times of stress - family problems, divorce, moving, taking exams, even going on vacations. But IBS is not a psychological problem; it has a physical cause. People with IBS have bowels that go into spasms more easily than those who don't, and scientists don't yet know why.

What they do know is that certain types of foods (milk, chocolate, caffeine) can trigger IBS in both children and adults. And IBS symptoms often improve when these foods are limited. Increasing fiber in the diet, and using techniques to relieve stress also seem to help. If necessary, your child's doctor may prescribe medicines to relieve symptoms.

Lactose Intolerance
For many children, an ice cream sundae or a cool glass of milk at lunch means an afternoon of cramps, gas, and diarrhea. If this happens to your child, he may be one of the more than 30 million Americans who have lactose intolerance. This condition is common in Americans with Asian, African, and Mediterranean family origins. Across the world, about 70% of all people may have some degree of lactose intolerance.

In this condition, the body manufactures too little lactase, an enzyme found in the intestines. Lactase breaks down lactose, a sugar that's found in milk and milk products. When lactose isn't broken down in the intestines, it ferments and causes gas and diarrhea.

If you notice that milk products seem to affect your child's digestive system, talk to your child's doctor. Growing children still need the calcium and vitamins found in dairy products. So if milk is a problem for your child, your child's doctor can suggest other types of foods that will supply these nutrients. Dairy products made especially for persons with lactose intolerance are sold in many supermarkets. Lactase enzyme supplements are also sold as drops and tablets. These are safe for children and may be used as your child's doctor recommends."

www.kidshealth.org/

This is also something very much worth reading

Mind-Body-Pain Connection: How Does It Work?

By Michael Henry Joseph
WebMD Live Events Transcript

Event Date: 05/11/2000.

Moderator: Welcome to WebMD Live's World Watch and Health News Auditorium. Today we are discussing "The Mind-Body-Pain Connection: How Does It Work?" with Brenda Bursch, Ph.D., Michael Joseph, M.D., and Lonnie Zeltzer, M.D.

Brenda Bursch, Ph.D., is the Associate Director of the Pediatric Pain Program, Co-Director of Pediatric Chronic Pain Clinical Service and Assistant Clinical Professor of Psychiatry & Biobehavioral Sciences at UCLA Department of Pediatrics in the School of Medicine. She has written about asthma, developmental & behavioral pediatrics, emergency medicine, AIDS education and prevention, chronic digestive diseases and pediatric bowel disorders. She has membership in the American Pain Society, American Psychological Association, Munchausen Syndrome by Proxy Network, and the UCLA Center for the Study of Organizational and Group Dynamics.

Michael Henry Joseph, MD, is an assistant professor of pediatrics and co-director of Chronic Pain Services at the University of California at Los Angeles Children's Hospital. He is a recipient of the Golden Apple Award for Excellence in Teaching.

Lonnie Zeltzer, M.D., is an expert in the field of pediatric pain. She is a former president of the Society for Adolescent Medicine and member of the National Institute of Health?s Human Development Study Section. She is currently a Professor of Pediatrics and Anesthesiology at the UCLA School of Medicine. She is Director of the UCLA Pediatric Pain Program and Associate Director of the Patients & Survivors Section, Cancer Prevention and Control Research Branch of the UCLA Jonsson Comprehensive Cancer Center. She has well over one hundred scientific publications, reviews and chapters in medical journals, and has lectured internationally.

http://www.webmd.com/content/article/1/1700_50465

this is another important one

The Other Brain Also Deals With Many Woes

http://www.nytimes.com/2005/08/23/health/23gut.html?ex=1282449600&en=1e310e52565798bf&ei=5090&partner=rssuserland&emc=rss

Hypnotherapy can be used with a 11 year old. Not a problem and kids usally respond very well to it.

This is important, the hypno does not have to be used just for stress and anxiety IBS but on IBS in general, stress and anxiety reduction are side effects and part of the process, but HT has shown to change physical issues in regards to IBS.

Reading the "first year IBS" can help for the information and eating for IBS.

Its important to treat young people early on for the best results later on in there life.

This is important for parents to know also.

http://www.kiwiterapi.dk/whiplash/frames/gutthoughts.htm

--------------------
My website on IBS is www.ibshealth.com

Print Remind Me Notify Moderator

Its extremely unlikely its SIBO, she doesn't match the symptoms for one. Of course you could get a test for it, but I think its unlikely the problem.

IBS and SIBO are also two different conditions. Despite some of the controversy lately about it, although its possible for them to overlap. I could explain if you wish.

She does match IBS if anything and her age is also more the likelyhood its IBS.

Gas can cause pain because of sensitive nerves linig the gi tract in IBS.

The chemical the gut releases to signal to the brain sensations in the gut is serotonin and they know there is a problem with that in IBSers.

All pain is processed in the brain. There is an impairment in IBS in a particular part of the brain called the Anteior Cinculate Cortex, so the signals coming from the gut can be not working right.

I might have missed something, but what testys has she had done.

Bloodwork
stool tests (three)
colonoscopy?

You might also want to read this.

http://hopkins-gi.nts.jhu.edu/pages/latin/templates/index.cfm?pg=disease1&organ=6&disease=43&lang_id=1

and this

with permission

Frequent stomachaches in
children: a reason for concern?
By Miranda Van Tilburg, PhD
Assistant Professor of Medicine
Division of Gastroenterology and
Hepatology
School of Medicine
The University of North Carolina at
Chapel Hill
Most children will complain of
a stomachache once in a while,
because it is one of the most common
childhood pain experiences.
Complaints can range from a vague
queasy feeling in the stomach to
doubling over in pain accompanied
by vomiting, diarrhea or constipation.
Fortunately, in a majority of cases,
the reasons for a stomachache are minor and
relatively benign. Most often, the complaint
settles without a specific diagnosis, even when
a doctor is consulted.
However, some children are more prone to
developing abdominal pain than others. These
children experience frequent stomachaches
over a period of several months to several years,
which can be very disrupting in the child's life.
Due to (a fear of developing) stomachaches,
these children often miss out on family events,
social outings with friends, and attending school.
Stepping out of normal life in this way makes
these children vulnerable to loneliness, anxiety,
depression and low self-esteem.
In the late 1950's, the English pediatrician John
Apley was one of the first to systematically study
and describe this phenomenon of childhood
stomachaches, which he named Recurrent
Abdominal Pain (RAP). In his first monologue on
RAP, Apley describes the typical situation of a
child who complains of frequent stomachaches.
This child has been sent home from school
and may even have vomited however, by the
time he arrives at the doctor's office, the pain
is usually gone and upon examination nothing
but indefinite tenderness in the abdomen is
found. The doctor usually does not find anything
definitive on which to base a diagnosis. Most
likely, the child has had the stomach pain before
�
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as well as somebody in his immediate family. The
pediatrician feels he or she can wait for further
developments with the child but has doubts
about having missed something. Was (s)he right
to express only reassurances or should further
investigations have been carried out? This
description of the pain-prone family
and doubtful physician is still true
today.
What is RAP?
Apley defined RAP as at least three
episodes of pain occurring within
three months that are severe enough
to affect the child's activities. This
diagnosis is still widely used in
clinical practice and research.
Sometimes, Rome classification
is used, with the most common
diagnoses being Functional
Dyspepsia (FD) or Irritable Bowel
Syndrome (IBS). FD is diagnosed when there
has been at least 12 weeks of persistent or
recurrent pain in the upper abdomen, without
evidence of organic disease and no relief with
defecation or change in stool form or frequency.
IBS is diagnosed when there has been at least 12
weeks of abdominal pain, without structural or
metabolic abnormalities and at least two of the
following three features -- relief with defecation,
change in stool frequency, or change in stool
consistency. Upon careful review of RAP patients,
it is found that pediatric IBS is very common � 45
to 70% of RAP patients meet Rome criteria for
IBS and about 16% are ascertained to suffer from
functional dyspepsia.
Nobody is in as much pain as my child
RAP patients and their parents often believe their
symptoms are unlike "normal" stomachaches
reported by other children. Pediatricians and
gastroenterologists, on the other hand, perceive
RAP as a problem that is overflowing their
practices. The truth lies somewhere in between
these two perspectives. RAP is one of the most
common chronic pain complaints in childhood,
but only 10 to 25% of children are affected.
Symptoms often wane with time and spontaneous
remission of RAP is likely. Yet, more than half
of RAP children will continue to suffer from
frequent somatic or psychological symptoms
into adulthood. For example, Christensen and
Mortensen reported that 11 out of the 18 RAP
patients in their study suffered from abdominal
pain 29 years later.
Frequent stomachaches in children: a reason for concern?
Miranda Van Tilburg
3
out as early as possible. Depending on the symptoms, a
physician can order blood, urine and stool tests to rule
out some common conditions. But, the use of X-rays, CTscans
and endoscopies are usually restricted to cases in
which the history or physical exam raises questions as to
the diagnosis. Even with extensive testing, the odds are
against finding an organic cause for a child who meets
symptom criteria for RAP. In only one out of 10 cases,
an organic cause can be identified and misdiagnosis
is extremely rare. Even up to 20 years after an initial
diagnosis of RAP, the chance of identifying an initially
undiagnosed organic disorder is very low.
Is it all in your head?
Apley believed that if there is no organic cause for the
pain, then the stomachaches are psychogenic. In other
words, RAP patients suffer from an emotional disorder.
He came to this conclusion because stress seemed to
exaggerate or precede pain attacks and psychotherapy
was usually effective in relieving attacks. In trying to
explain the absence of abnormal physiological findings,
many have followed Apley's lead and suggested these
children suffer from psychological problems. RAP
patients have been described as fussy, perfectionistic,
high strung and anxious, and several studies have
shown they suffer from more psychological problems
than healthy children.
However, the landmark work of Walker & Greene
has shown that anxiousness is a consequence of the
presence of abdominal pain rather than a cause. RAP
patients are not necessarily more anxious or depressed
than patients suffering from peptic ulcer or IBD, in which
the abdominal pain is caused by inflammation of the GI
tract. These findings suggest that chronic abdominal pain
affects patients in similar ways regardless of etiology,
and the notion that RAP is a psychogenic disorder has
now fallen largely out of favor. Psychosocial factors are
assumed to influence GI functioning and can exaggerate
symptoms, but they play only a limited causal role.
Suffering from abdominal pain does, however, generate
psychological distress. It can produce not only anxiety
but also increased depressive symptoms, somatization
and lower self-esteem. Now it is understood that the
cause of RAP is neither organic nor psychogenic,
but there is close interplay between physiology and
psychology.
What is causing RAP?
Although no structural abnormalities or diseases
may be found, RAP patients do show some abnormal
physiological characteristics. There is growing evidence
that a disruption in the functioning of the GI tract is one
of the major causes of RAP. This basically means that the
Frequent stomachaches in children: a reason for concern?
In other words, RAP patients suffer
from an emotional disorder. He came
to this conclusion because stress
seemed to exaggerate or precede
pain attacks and psychotherapy was
usually effective in relieving attacks.
Are RAP stomachaches real, imagined or faked?
Since stomachaches are notoriously used as an excuse
for skipping school, they have gotten a bad reputation.
A child with RAP is often thought of as a whiner who
uses his bellyaches to get attention or get out of things,
especially when a physiological cause for the pain
cannot be identified. RAP children and their families
face this type of prejudice almost daily, even among
many health care professionals. However, it is important
to understand that the pain of RAP is real and not faked
or imagined. Even abdominal pain caused by stress
or worry about going to school is usually real. Most
children never think about faking it. Acknowledging the
validity of RAP stomachaches is the right thing to do,
but keeping a child who suffers from RAP out of school
every time he or she complains is not necessary. If no
other symptom, such as vomiting or fever is present, it
is usually safe for the child to go to school.
Has a serious disease been overlooked?
Both parents and physicians are often doubtful about
the diagnosis of RAP. There is no marker or test to
identify RAP; the diagnosis is made purely on the basis
of symptom characteristics. Common organic causes of
abdominal pain are usually ruled out before giving a
diagnosis of RAP. The list of disorders that can cause
abdominal pain is lengthy and, generally, it is neither
ethically nor financially possible to test every child for
all possibilities. Serious illnesses can sometimes explain
recurrent stomachaches and it is important to rule these
When RAP persists into adulthood, these patients
are most likely to develop IBS. There are striking
similarities between adulthood IBS and childhood RAP
in terms of prevalence, course, medical and psychiatric
co-morbidity, family medical and psychiatric history,
and stressful life events. There is data to suggest that
the prognosis is worse for children who have a parent
who suffers from recurrent pain and for children who
experience more negative life events. Therefore,
although it is true that some children will eventually
grow out of their stomachaches, there is a good chance
that abdominal or other somatic symptoms will reoccur
later in life.
4
bodies of children with RAP work somewhat differently.
This etiological model has been adapted largely from
research findings on adulthood IBS. As discussed earlier,
childhood RAP has many similarities with adulthood
IBS and many young RAP patients will have or develop
abdominal pain in their adult life. RAP is therefore often
seen as a precursor to adulthood IBS and identical
etiological mechanisms have been suggested. It is
important to realize, however, that few studies to date
have focused on etiological mechanisms of childhood
RAP compared to the extensive literature on adult IBS,
and findings have not always been identical.
It has been suggested that the Autonomic Nervous
System (ANS) is disrupted in RAP. The ANS consists of
neurons that run between the central nervous system
(e.g., the brain) and various internal organs, such as
the bowels and stomach. The ANS is responsible for
monitoring conditions in the internal environment
and bringing about appropriate changes in them.
For example, after eating, the ANS acts to ensure the
stomach and bowel contract to move the food through
the digestive tract. This happens largely involuntary,
although we do have some control over our bowels as
is shown by people practicing yoga or under hypnosis.
It has been suggested that the ANS in RAP is weak -- it
does not adapt to changes as effectively as in healthy
children. For example, after stimulation of the rectum,
RAP patients show slower recovery than children who
do not suffer from RAP.
A second mechanism that could explain RAP is
disruptions in motility (the speed with which food
moves through the digestive system). In many cases,
RAP is associated with either diarrhea or constipation.
This seems to suggest that food is either moving too
quickly or too slowly through the bowels and that this
motility problem could account for the pain. Some
studies have observed increased transit time in RAP
patients, but these findings have not been found in all
studies. Furthermore, adding fiber to the diet to slow
transit time has been found to benefit only a subgroup
of RAP patients.
Lately, visceral hypersensitivity has received
considerable attention as one of the major pathways that
causes RAP symptoms. Visceral hypersensitivity means
that nerves in the gut are very sensitive: RAP patients
feel pain in areas of the GI tract much more easily.
Because of this heightened sensitivity, RAP children
perceive 'normal' gastrointestinal events -- such as
small increases in motility or gas -- as painful.
There is convincing evidence of visceral hypersensitivity
in many adult IBS patients and it has been reported in
children with RAP, as well. This abnormal perception of
pain (low pain threshold) can be due to changes in both
the central (brain) and enteric (gut) nervous system.
Nerves in the gut can become overly sensitive and start
reacting to events that would otherwise be ignored. The
brain, on the other hand, can overreact by not inhibiting
as much information coming from the gut as usual,
thereby enabling more pain stimuli to pass through
into our awareness. Psychological distress can augment
these processes.
It should be emphasized that there might be different
etiologies explaining RAP. In some children abdominal
pain might be caused by disruptions in the ANS, while
for others the pain is due to an increase in motility or
visceral hypersensitivity, and for a third group the pain
may be largely psychogenic. It is very likely that in most
RAP patients multiple mechanisms can be identified
that influence each other. For example, frequent severe
pain due to increased motility may eventually lead to
hypersensitivity for motility which, in turn, generates
more pain due to heightened sensitivity to changes in
motility.
What about stress?
Many parents, children and physicians understand that
stress can exacerbate the pain. However, most studies
so far have failed to find a clear relationship between
major stressors (such as death or illness in the family, a
divorce, or a move) and the occurrence of RAP. It might
be possible that minor chronic stresses or daily hassles
-- such as having to wait in line at the store, quarrels
with siblings, constantly stopping for bathroom visits,
or vigilantly monitoring what one's eating -- may be
far more significant than the stress of major life events.
Unfortunately, there is still little research on the effects
of minor chronic stress.
Effectiveness in coping may be even more important in
explaining RAP than exposure to stress. When a child is
an effective coper, even high levels of stress might not
affect him or her very much. By contrast, an ineffective
coper is likely to become distressed when faced with
only minor setbacks in life. Coping with abdominal
pain and other stresses is often difficult for children
who suffer from RAP. Many RAP children use avoidance
strategies such as denial, avoiding thinking about it and
wishful thinking which, in turn, can result in elevated
levels of pain, somatic symptoms and distress. By
contrast, effectively adapting to (coping with) the pain
by regulating attention and cognitions (e.g., distraction,
acceptance of the pain or positive thinking) are
associated with less pain, fewer somatic symptoms and
Frequent stomachaches in children: a reason for concern? 5
less distress. Acting directly on the pain in an attempt to
change the environment or one's emotions (e.g., taking
medications, visiting a physician, reducing stress in
one's life) can be somewhat helpful, but these actions
do not appear to influence the pain very much.
Are non-GI symptoms related to RAP?
Children with RAP can present with a multitude of
other unexplained symptoms (co-morbidity), and
the physician may wonder if these are related to the
stomachaches. Co-morbid symptoms are important
since they may be indicative of: (1) psychological
problems that could either drive the GI symptoms or
be a consequence of coping with multiple pains, or
(2) more severe or longer duration of pain which can
trigger pain in other areas. Relatively little is known
about co-morbid somatic symptoms in RAP. About
half the children who report stomach pain indicate
more than one pain location. Multiple pain sites are
more commonly reported by girls than boys, and they
increase with age. The most common combination is
headache and abdominal pain and is reported in 25%
of cases with two sites of chronic pain.
In a study of RAP patients consulting a physician, the
number of co-morbid symptoms was found to increase
with the duration of RAP. In other words, one pain might
initiate other pain. But, it could also be possible that
only those patients who have multiple symptoms are
seen by a doctor over a longer period of time. Another
study did not find a relationship between the duration
of stomachaches and the occurrence of other symptoms
during a three-month follow-up of patients. However,
three months might have been too short a period of
time to see an effect. More research into associated
symptoms, who is at increased risk, and what is causing
the co-morbidity is needed.
Do more severe symptoms result in more
disability?
RAP has a large impact on suffering, health care costs
and functional disability. School absences are one of
the most common and obvious effects of RAP, and often
one of the first goals in therapy is to resume school
attendance. The RAP child who misses school also tends
to use more health care services. Health care resource
use is particularly high among RAP patients, but not all
children who suffer from RAP consult a doctor or miss
school. Currently, there is little research-based insight
into the characteristics of the child who is most likely to
miss school and consult a physician for stomachaches.
In a study by Hyams and colleagues, only 9% to10% of
middle and high school students with RAP reported they
had seen a doctor for abdominal pain within the last
year. But, students who did visit a doctor for abdominal
pain reported increased pain severity, frequency and
duration and more disruption of their lives. In a study
by Venepalli and colleagues, health care consulting and
school attendance of middle school children could not
be predicted by pain intensity or psychosocial distress
of either the mother or the child. Identification of children
who show high levels of functional disability is important,
because this would allow for targeting (preventive)
interventions, determining cost-effectiveness of care,
and preventing poor academic performance due to
school absences.
Are the parents to blame?
Physicians confronted with an anxious parent of a child
with RAP often feel these parents play a major role in
the maintenance and exacerbation of the symptoms.
Parents for RAP children, on the other hand, feel they
have no control over the situation and do not appreciate
being 'blamed' for their child's symptoms. It is important
to understand that a disorder seldom affects only the
patient. People around the person in pain are affected,
as well -- they can be stressed about the pain and its
meaning. In fact, many parents of children who suffer
from abdominal pain show increased levels of anxiety
and somatization themselves. This is a normal reaction
and does not imply that parents cause RAP.
However, parental beliefs, stress, and coping strategies
are of great influence on the child's pain perception
of pain. Children are still developing their coping
repertoires and look to adults for guidance about
when to get anxious or worried and how to deal with
symptoms. When a child is sick, in pain or discomfort,
parents have the difficult task of interpreting the
seriousness of the symptoms and deciding how to take
action. Any parental action or reaction will influence
how their children approach future illness and health.
How can a doctor help a child who suffers from
RAP?
Standard medical care for RAP consists of (1) limited
medical tests to rule out organic diseases, (2)
acknowledgment that the pain is real, (3) reassurance
that there is no illness causing the pain, and (4) advice
on how to cope with the symptoms. Parents and children
need to be partners with their physician in their health
and health care. Since most patients visit a physician in
search of a 'cure,' it is important for physicians to explain
that RAP is a chronic condition and that returning to
normal life as much as possible is the goal, rather than
complete pain relief. Medications can be given to treat
accompanying symptoms, such as constipation.
6 Frequent stomachaches in children: a reason for concern?
Many RAP patients may come to the doctor's office with
questions about diet. In fact, most of them will have
changed their eating behavior before seeing a doctor.
They may propose that food sensitivities, unhealthy
diets or dysfunctional eating patterns are possible
causes of the symptoms. At this time, there is only
limited data on the effects of diet on RAP symptoms.
The most extensively studied are the influence of
lactose malabsorption and lack of sufficient fiber in the
diet. Many parents will have placed their children on
a lactose-free diet, but the majority of patients do not
report benefits from this dietary restriction. Even lactoseintolerant
children do not necessarily see a significant
improvement in their RAP symptoms, suggesting that
lactose intolerance might be an additional dysfunction
the child is dealing with but it is not a major cause for
the stomachaches. As mentioned above, fiber therapy
can be helpful in some cases, but the currently limited
research data is conflicting with regard to its benefit.
Nevertheless, some suggest that because of its low cost
and low risk, it might be worthwhile to try high fiber
therapy in children presenting with RAP.
Although standard medical care can result in significant
improvements, many RAP patients need additional
therapy. Psychological therapies such as Cognitive
Behavioral Therapy (CBT) have been found to be
effective in treating RAP. CBT teaches children and/or
their parents to change unhelpful thoughts about the
disorder and learn effective coping skills, and it is often
combined with relaxation exercises. CBT has been shown
to produce significant improvements in pain, health care
utilization and school attendance. Unfortunately, these
therapies are not available to a majority of the RAP
patients. They require multiple meetings with a highly
trained therapist, insurance often does not necessarily
cover these costs, and most physician offices lack the
time and resources to implement such a program. There
is a need for effective psychological treatments for RAP
that are more accessible.
There is no quick fix for RAP and the road to recovery can
be bumpy and challenging for all parties. Patients and
their families may feel misunderstood and discouraged
by relapses. Physicians might feel they are not able to
convey their message to the family or lack the time to
give adequate coping advice. Although RAP is a very
challenging disorder, there are many ways in which
children, their parents and physicians can help to ease
the pain. No one approach will work in every child, but
the right combination of understanding the disorder
and its causes, medications, reduction of stress, changes
in eating and bowel movement patterns, coping advice,
and encouragement to fully participate in school and
social life can be of great benefit in managing, reducing
and controlling the pain. For many children, the care and
encouragement of a good physician will be sufficient to
take control over the symptoms.
However, for children needing additional care, it can
be challenging to find the right therapist or therapies.
This gap is recognized and more research is being
done in developing behavioral interventions. For
example, the UNC Center for Functional GI & Motility
Disorders is currently partnering with Dr. Rona Levy at
the University of Washington to test a short Cognitive
Behavioral Therapy for RAP in which both the children
and parents are involved. At UNC, we are also in the
process of developing a hypnosis program for RAP that
can be used by any health care professionals without
extensive training, making it more widely available to
many patients. Some pediatric gastroenterologists are
already teaming up with therapists who have specialized
in pediatric GI disorders.
In sum, the most important intervention for children
who suffer from recurrent abdominal pain is to reassure
them that we understand their pain is real but also that it
can be managed with appropriate medical care and/or
psychological therapy.
Selected reading (a complete reference list can be obtained from the
author)
Apley J, Naish N. Recurrent abdominal pain: A field study of 1000
school children with recurrent abdominal pain. Archives of Diseases
of Childhood 1958;46:337-340.
Scharff L. Recurrent abdominal pain in children: a review of
psychological factors and treatment. Clin Psychol Rev 1997;17:145-
166.
Christensen MF, Mortensen O. Long-term prognosis in children with
recurrent abdominal pain. Arch Dis Child 1975;50:110-114.
Hyams JS, Burke G, Davis PM, Rzepski B, Andrulonis PA. Abdominal
pain and irritable bowel syndrome in adolescents: a communitybased
study. J Pediatr 1996;129:220-226.
Venepalli N, Van Tilburg MAL, Whitehead WE. Recurrent Abdominal
Pain (RAP): The relationship between illness behaviors and health
services consulting? American Journal of Gastroenterology
2004;126:A372.
Walker LS, Greene JW. Children with recurrent abdominal pain and
their parents: More somatic complaints, anxiety, and depression than
other families? Journal of Pediatric Psychology 1989;14:231-243.
Walker LS, Garber J, Greeene JW. Psychosocial correlates of recurrent
childhood pain: A comparison of pediatric patients with Recurrent
Abdominal Pain, organic illness and psychiatric disorders. Journal
of Abnormal Psychology 1993;102:248-258.
Walker LS, Claar RL, Garber J. Social consequences of children's
pain: when do they encourage symptom maintenance? J Pediatr
Psychol 2002;27:689-698.
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7 Frequent stomachaches in children: a reason for concern?

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