Kids' distress is no small thing
http://www.usatoday.com/news/health/2005-05-08-kids-pain_x.htm
New Recommendations for Treating Children With Chronic Abdominal Pain CME
http://www.medscape.com/viewarticle/500799
Mind-Body Technique Eases Kids' Gut Pain
Kids Have Fewer Days of Abdominal Pain When Using Relaxation Technique WEBMD
http://www.webmd.com/content/article/72/81542.htm
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
Recurrent abdominal pain in children: forerunner to adult ir
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FYI
J Spec Pediatr Nurs. 2003 Jul-Sep;8(3):81-9. Related Articles, Links
Recurrent abdominal pain in children: forerunner to adult irritable bowel syndrome?
Jarrett M, Heitkemper M, Czyzewski DI, Shulman R.
Department of Biobehavioral Nursing and Health Systems, University of Washington, Seattle, USA. jarrett@u.washington.edu
ISSUES AND PURPOSE: Review the etiology and pathophysiology of recurrent abdominal pain (RAP) and its potential role as a precursor to irritable bowel syndrome (IBS) in adults. CONCLUSIONS: Physiological mechanisms not easily identifiable as an organic cause may underlie symptoms in RAP patients. They may be triggered by psychosocial factors that result in greater functional disability, more clinic visits, and lower academic and social competence. Of these children, 25% will experience similar symptoms as adults; many will be diagnosed with IBS. PRACTICE IMPLICATIONS: Nurses can provide early and efficient management of these children's care if they view the issues of abdominal pain/discomfort from a broader focus that includes the context of the child's experiences.
PMID: 12942886
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
Top Pediactric docs and pain webmd
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?src=Inktomi&condition=Event%20Archives
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