• Complete blood count with diff erential • Erythrocyte sedimentation rate • Comprehensive metabolic panel • Stool hemoccult
DIARRHEA
• Stool ova and parasite
• Giardia enzyme-linked immunosorbent assay
• Clostridium diffi cile toxin or PCR
• Celiac panel
• Lactose or fructose breath test • Dyspepsia
approached as a biopsychosocial phenomenon. FAP is still real pain. However, the response to pain can be subjective and understood through life experience. Th e treatment may there- fore be a combination of psychotherapy, pharmacology, dietary, or alternative medicine techniques. It must always begin with educating the child and parent about the cause of the pain and the treatment plan. Th is approach not only improves the adherence to the treatment plan but also has been shown to aff ect the outcome. Treatment response may be infl uenced by whether the parents perceive the pain to have an organic cause.28 Similarly, children of parents who are open to a psychiatric consultation are more likely than not to report less pain.28
X MANAGEMENT
A discussion of FAP as a real entity that is a product of an alteration in the brain-gut axis makes understanding the cause of the pain easier for parents. A good analogy is that of a migraine: no specifi c test exists to confi rm the diagnosis, but stress and other inciting events may trigger a headache. When explained this way, parents may be better able to understand that the current thinking of autonomic dysfunction and visceral hypersensitivity as causes of the child’s recurrent FAP does not mean that the pain is purely in the child’s head or solely the eff ect of an undiagnosed physical ailment. Equally important is to inform the parents that the goal of therapy is not so much to arrive at a diagnosis, but rather to be able to have the child resume the lifestyle that preceded the onset of the abdominal pain, including school attendance, sleep patterns, and appetite.
Psychosocial Treatment
Several diff erent psychological strategies have been tried in a variety of conditions associated with functional pain, including treatment aimed at individuals or parent–child couples in one-to-one contacts with a therapist, group-based interventions, or a mixture of individual and group treatment. Psychological treatments, principally relaxation and cognitive-behavioral therapy, are eff ective in reducing the severity and frequency of chronic headache in children and adolescents. However, no evidence has been found for the eff ectiveness of psychological therapies in attenuating pain in conditions other than headache.29,30
Cognitive-behavioral therapy that combines operant elements and stress management may provide an eff ective treatment for FAP, however.31 Cognitive-behavioral therapy results in short-term improvement, with more than one-half of patients experiencing freedom from pain.32,33 Th e child’s coping skills and the parent’s caregiving strategies predict the eff ectiveness of treatment.34 Disengagement and involuntary engagement are correlated with increased anxiety, depression, and somatic symptoms. Anxiety as a comorbidity has also been associated with FAP,35 and therefore psychological therapy may be used as a strategy in treating FAP.
Alternative medical techniques for the treatment of functional gastrointestinal disorders, including FAP of childhood, are becoming more common.36 Specifi c mind-body techniques include various breathing techniques, guided imagery, progressive muscle relaxation, bio- feedback, hypnosis, cognitive-behavioral training, and music therapy. Of those techniques, guided imagery, relaxation, biofeedback, and hypnosis have shown the most promise in treating FAP of childhood. Reported improvement in the pain, fewer school absences, better engagement in social activities, and fewer visits to the physician’s offi ce may result
Abdominal Pain 23
from guided imagery and progressive relaxation techniques taught over approximately 4 offi ce visits.37 Such techniques are easy to learn and teach and are offi ce friendly, even with children.
Medication
Many drugs have been used in the attempt to treat FAP in childhood, including famoti- dine, pizotifen, and peppermint oil.38 Peppermint oil in the form of a pH-dependent, enteric-coated capsule has been shown in evidence-based studies to be helpful in alleviating abdominal pain. Other commonly used medications are anticholinergics, antiemetics, anti- depressants, and simethicone, but they have not yet been adequately studied. Citalopram, a selective serotonin reuptake inhibitor, has been used to treat FAP, with improvement of abdominal pain, anxiety, depression, and functional impairment.35 Amitriptyline has also been shown to reduce pain, depressive symptoms, and somatization in children with FAP and irritable bowel syndrome.39
Probiotics have been used to treat alterations in gut fl ora in ulcerative colitis and antibiotic-associated diarrhea, but there is little evidence to support their use in FAP. Only one study has shown that the probiotic VSL#3 improves abdominal pain as well as bloating, gassiness, discomfort, and quality of life in patients with irritable bowel symp- toms. Other studies suggest that Lactobacillus GG does not relieve abdominal pain but can decrease its frequency and reduce bloating.40
Dietary Interventions
Dietary manipulation has been used to treat the pain in functional disorders. Common dietary interventions include a high-fi ber diet, avoidance of lactose, an oligoantigenic diet, and a low-oxalate diet in abdominal migraine.41 A high-fi ber diet may be helpful primarily in constipated children, to substitute for nutrient-poor, high-fat, and high-calorie diets. Avoidance of high-fructose corn syrup and glucose-based drinks and of sugar-free gum and candy may improve symptoms. Sorbitol, the sugar substitute in gum and candy, can cause bloating, cramping, abdominal pain, and diarrhea. Dietary manipulation is easily understood by parents and children and can empower the family.
X CONCLUSION
Th e causes of abdominal pain range from acute, life-threatening disease to chronic, functional conditions. Regardless of the cause, the consequences of abdominal pain can be far reaching and can aff ect not only the emotional and psychological well-being of the child but also the social and economic dynamics of the family. Th e need to diagnose and treat emergent conditions quickly must be balanced with unnecessary testing when a functional cause seems likely. In the case of functional conditions, a caring approach that educates and reassures the patient and parents is essential for good adherence and an eff ective therapeutic relationship.
When to Refer
• Involuntary weight loss • Deceleration of linear growth • Gastrointestinal blood loss
• Signifi cant vomiting • Chronic severe diarrhea
• Persistent right upper or right lower quadrant pain • Unexplained fever
• Family history of infl ammatory bowel disease • Extraintestinal symptoms
• History of psychiatric disorder • Abnormal test results
• Anemia or low mean corpuscular volume • Peripheral eosinophilia
• Increased erythrocyte sedimentation rate • Increased transaminases
• Increased blood urea nitrogen or creatinine • Hypoalbuminemia
• Low complement-4 protein
When to Admit
Hospitalization is seldom indicated for patients with FAP; in fact, some studies suggest that placing patients with FAP in the hospital may lead to worse outcome. Some patients do experience relief of symptoms during hospitalization. However, no data suggest that the natural history of the pain is aff ected. Hospitalization does not help the fundamental goals of environmental modifi cation and will likely reinforce pain behavior. Hospitalization is required in the following circumstances:
• Surgical or medical emergency as determined by diagnostic or therapeutic intervention • Inability to tolerate enteral nutrition
• Inability to maintain hydration
• Diagnosis that requires observation to evaluate the progress or natural history of the illness
TOOLS FOR PRACTICE
Engaging the Patient and Family
• Abdominal Pain (Web page), American Academy of Pediatrics (www.healthychildren.
org/English/tips-tools/Symptom-Checker/Pages/Abdominal-Pain.aspx)
• Abdominal Pain in Children (fact sheet), American Academy of Pediatrics (www.
healthychildren.org/English/health-issues/conditions/abdominal/Pages/Abdominal- Pain-in-Children.aspx)
• Abdominal Pain in Infants (fact sheet), American Academy of Pediatrics (www.
healthychildren.org/English/health-issues/conditions/abdominal/Pages/Abdominal- Pains-in-Infants.aspx)
Medical Decision Support
• Pediatric Nutrition Handbook, 7th ed (book), American Academy of Pediatrics (shop.
aap.org)