ArticlePDF AvailableLiterature Review

Practical management of functional abdominal pain in children


Abstract and Figures

Functional abdominal pain (FAP) is common in childhood, but is not often caused by disease. It is often the impact of the pain rather than the pain itself that results in referral to the clinician. In this review, we will summarise the currently available evidence and discuss the functional dimensions of the presentation, within the framework of commonly expressed parental questions. Using the Rome III criteria, we discuss how to classify the functional symptoms, investigate appropriately, provide reassurance regarding parental worries of chronic disease. We outline how to explain the functional symptoms to parents and an individualised strategy to help restore function.
Content may be subject to copyright.
Practical management of functional abdominal pain
in children
L K Brown,
R M Beattie,
M P Tighe
Department of Paediatric,
Poole Hospital NHS Trust,
Poole, Dorset, UK
Department of Child Health,
University Hospital
Southampton, Southampton,
Correspondence to
Dr M P Tighe, Department of
Paediatrics, Poole Hospital NHS
Trust, Longeet Rd, Poole
BH15 2JB, Dorset, UK;
Received 8 September 2015
Revised 30 October 2015
Accepted 4 November 2015
To cite: Brown LK,
Beattie RM, Tighe MP. Arch
Dis Child Published Online
First: [please include Day
Month Year] doi:10.1136/
Functional abdominal pain (FAP) is common in childhood,
but is not often caused by disease. It is often the impact
of the pain rather than the pain itself that results in
referral to the clinician. In this review, we will summarise
the currently available evidence and discuss the functional
dimensions of the presentation, within the framework of
commonly expressed parental questions. Using the
Rome III criteria, we discuss how to classify the functional
symptoms, investigate appropriately, provide reassurance
regarding parental worries of chronic disease. We outline
how to explain the functional symptoms to parents and
an individualised strategy to help restore function.
A 9-year-old girl presents with central abdominal
pain for 4 months. The pain occurs approximately
once a week and has affected school attendance.
The pain is moderate in severity and remits after
some hours. Analgesia does not help. There is no
associated change in bowel habit; she sometimes
passes a hard stool. There is no vomiting or weight
loss. Examination is entirely normal. Her mother is
concerned that no cause has been found. The
mother wonders if it is irritable bowel syndrome as
she herself has this condition. The child is doing
well at school.
‘….at least 3 bouts of pain, severe enough to affect
activities, over a period of not less than three
Recurrent abdominal pain (RAP) is a common
presentation to general practitioners and paediatric
outpatient clinics. A prevalence of 1030% has
been reported, with some studies showing a higher
rate in females. Peaks in age occur from 46 years
of age, and 911 years; however, children outside
these age groups often present with symptoms.
Currently, paediatric functional gastrointestinal
(GI) disorders are categorised within the Rome
Criteria III (table 1).
The most commonly occur-
ring subtype is irritable bowel syndrome (IBS), in
up to 65%, followed by functional abdominal pain
(FAP) (35%), then, less commonly, FAP syndrome,
functional dyspepsia and abdominal migraine,
although there is often some overlap.
The biopsychosocial model of pain explains how
abdominal pain occurs as a result of interplay
between multiple factors surrounding the child,
including genetic predisposition, life events, the
family and the childs coping mechanisms for
dealing with stress and pain (table 2). These bio-
logical, social and psychological factors impact the
development and recognition of gut pain through
altered gut physiology via the braingut axis.
Giving the family an understanding of how pain
can be generated without noxious stimuli is key to
managing RAP. Figure 1 is a simplied schema that
may help patientsand parentsunderstanding.
Central and visceral hypersensitivity are key con-
cepts and underpin the perception of the truepain
of RAP. Physical and emotional stress causes an
increase in the concentration and sensitivity of pain
receptors, and production of pain-mediating neuro-
transmitters in the gut, at spinal and cerebral levels.
Upregulation of these pain-generating pathways has
been seen in patients with FAP syndrome in adults,
mostly in studies into IBS.
In IBS, increased gut
motility and visceral hypersensitivity seems to cor-
relate with symptom development. In children with
RAP, abnormalities in cells secreting serotonin and a
higher frequency of mast cells close to enteric nerve
cells have been demonstrated, which may be evi-
dence of gut wall physiology alterations.
Such mechanisms may explain what is thought to
be a lowering of the individuals pain threshold,
leading to functional processes of the gut being per-
ceived as painful. Reducing psychological stress
leads to downregulation of these systems and
reduction in pain, allowing targeted therapies to be
Communication of the biopsychosocial theory of
pain is valuable in the childs recovery; if parents
and the child accept the role of the biopsychosocial
components of pain, this is strongly associated with
a positive prognosis. This was demonstrated in a
small but long-term study (28 children) that
showed at a mean of 3.5 years follow-up, half of
children were pain free. Seventy-eight percent of
parents of children who recovered believed that
psychological factors were the underlying cause
and reported that identifying psychological stres-
sors was important in recovery.
Clinical bottom line
Establishing the functional nature of symptoms and
helping parents to understand that symptoms are
not manifestations of disease, but are due to vis-
ceral hypersensitivity, which is modiable, lays
solid foundations for long-term recovery.
Genetic factors
Family studies have suggested an inheritable pattern
of functional symptoms. One familial study linked
the increased familial presence of abdominal symp-
toms with those patients reporting IBS (OR 2.3;
Brown LK, et al.Arch Dis Child 2015;0:17. doi:10.1136/archdischild-2014-306426 1
ADC Online First, published on March 10, 2016 as 10.1136/archdischild-2014-306426
Copyright Article author (or their employer) 2016. Produced by BMJ Publishing Group Ltd (& RCPCH) under licence. on March 11, 2016 - Published by from
95% CI 1.3 to 3.9).
Another study found that adults with IBS
were three times more likely to have siblings with a functional
gut disorder.
Twin studies also identied a genetic predisposition to RAP
syndromes. The genetic concordance of 8.4% was seen between
dizygotic twins versus 17.2% in monozygotic twins.
the study also looked at the prevalence of IBS in parents and
using logistic regression found that having a parent with IBS
was a stronger predictor of IBS than having a twin with IBS.
This work strongly suggests that family environment plays a
major role in the development of IBS.
A later twin study aimed to establish genetic links for gastro-
oesophageal reux disease (GORD), dyspepsia and IBS. A stron-
ger association for monozygotic twins than dizygotic twins was
seen in GORD (OR 1.5; p=0.002) and IBS (OR 1.12; p=0.05)
but not dyspepsia (p=0.6). Statistical signicance did not persist
after logistic regression was performed to remove potential con-
founding variables of anxiety and depression.
This augments
the evidence for psychological stressors contributing to func-
tional GI disorders.
Clinical bottom line
A trend was noted within families for RAP syndromes, high-
lighted in identical twins compared with non-identical twins. In
IBS and GORD, maternal functional symptoms and psycho-
logical stressors are also signicant contributing factors.
Family factors
Life events
Events such as loss of a parent in childhood, through death,
divorce or separation are emotional and stressful times and need
careful consideration when considering how external stress
impacts on the child (and family). Additional factors include
change in school, examinations, competitions and pressure from
extracurricular activities, which may precipitate or impact on
the perception and severity of symptoms. The possibility of
Table 1 The Rome III diagnostic criteria for abdominal pain-related functional gastrointestinal disorders
Characteristics of pain Other diagnostic criteria
Functional dyspepsia
Persistent or recurrent pain or discomfort centred in the upper abdomen Not relieved by defecation or associated with the onset of a change in stool frequency or stool
form (ie, not irritable bowel syndrome)
No evidence of an inflammatory, anatomic, metabolic or neoplastic process that explains the
childs symptoms
Irritable bowel syndrome
Abdominal discomfort* or pain associated with two or more of the
following at least 25% of the time
A. Improvement with defecation
B. Onset associated with a change in frequency of stool
C. Onset associated with a change in form (appearance) of stool
Abdominal migraine
1. Paroxysmal episodes of intense, acute periumbilical pain that lasts for
1 h or more
2. Intervening periods of usual health lasting weeks to months
3. The pain interferes with normal activities
Pain associated with two of the following:
A. Anorexia
B. Nausea
C. Vomiting
D. Headache
E. Photophobia
F. Pallor
Functional abdominal pain
Episodic/continuous abdominal pain Insufficient criteria for other functional gastrointestinal disorders
Functional abdominal pain syndrome
Must satisfy criteria for childhood FAP and be present for at least 25%
of the time
1. Some loss of daily functioning
2. Additional somatic symptoms such as headache, limb pain or difficulty sleeping
*For all syndromes, the following criteria apply: no evidence of an inflammatory, anatomic, metabolic or neoplastic process considered that explains the subjects symptoms. The most
recent iteration of the Rome criteria reduced the duration of pain required for diagnosis from 3 to 2 months, except abdominal migraine: described as acute episodic pain occurring over
1 year.
Table 2 Factors contributing to the development and progression of recurrent abdominal pain
Physical Psychosocial
Recent physical illness Poverty
Postviral infection/postviral gastroparesis Death of a family member
Food Intolerancepoor diet, wheat, carbohydrate intolerance, excess sorbitol Separation of a family memberdivorce, child going to college
Different and/or multiple medications, eg, non-steroidal anti-inflammatory drugs, anti-spasmodics Altered peer relationships
Constipation School difficulties with academic progress or exam stress
Chronic illness Illness in parents or sibling
Lack of exercise Geographical move
2 Brown LK, et al.Arch Dis Child 2015;0:17. doi:10.1136/archdischild-2014-306426
Review on March 11, 2016 - Published by from
abuse, in any form, should always be considered when children
report illness that poses a diagnostic challenge.
Early studies noted that emotional childrenwere more prone to
developing FAP.
More recently, it has been shown that children
with FAP internalise problems and are more likely to have emo-
tional disorders
including anxiety. One study of 237 children
showed an association between higher anxiety scores (p<0.001),
higher depression scores (p<0.001) and worse quality of life
(p<0.001) with increasing severity of abdominal pain.
In a separate study regarding childhood chronic pain, includ-
ing FAP, psychiatric diagnoses of anxiety or depression were
commoner versus age-matched controls without chronic pain
(p<0.001). In the FAP group, at least one psychiatric disorder
was seen in 52.6% of children (N=19).
A variety of depres-
sion and anxiety disorders have been reported, including separ-
ation anxiety, general anxiety and social phobia.
15 17 18
Coping with stress
Children with FAP are more likely to describe themselves as
being unable to actively change their situation when faced with
adversity. Such children are less likely to accommodatestress,
to accept difculties, encourage themselves to keep going and
readjust with a positive outlook. This may promote negative
affect and worsen abdominal pain.
The family and parental inuence on pain
The home and family dynamic inuence functional symptoms
in multiple ways. The effect of living among a family in conict
is related to higher functional disability in children with RAP. In
78 children with functional symptoms, the childs symptom
scores were compared with the family environment scale, and
aspects such as family conict and family organisation were sig-
nicantly correlated on multiple regression analysis (family con-
ict, β=0.43, r
change=0.18, p<0.001, and lack of family
organisation, β=0.30, r
change=0.09, p<0.01) perhaps as
the childs pain may be diversionary.
Particular roles can
emerge, the child adopting a sick roleand a parent the care-
the caregiver may extend their role; reinforcing symp-
toms, rather than encouraging rehabilitation.
Parental abdominal pain and mental health problems are risk
factors for FAP in their offspring. Early studies revealed that
children of parents with GI symptoms had a higher incidence of
abdominal pain (p<0.005).
Mothers of children with FAP
have a higher incidence of depression, anxiety and somatic
scores compared with mothers of children without FAP.
In a
cohort of 6 year olds, maternal anxiety predicted continuing
pain at 7 years (OR 2.57; CI 1.13 to 5.86), school absenteeism
(OR 1.77; CI 1.04 to 3.03) and anxiety in the child (OR 2.72;
CI 1.25 to 5.92).
Also, children of mothers with higher educa-
tional attainment were at greater risk of developing FAP.
High achievers are felt to be particularly vulnerable to FAP,
although there is a paucity of high-quality evidence. One study
noted higher admission rates for non-specic abdominal pain
were seen within term time compared with holidays (rate ratio
1.42: 95%CI 1.25 to 1.61).
Further questioning could high-
light factors such as school holidays providing relief from stres-
sors or separation anxiety contributing to school refusal.
Clinical bottom line
Exploring the stressors provides an important insight into
family dynamics and limits unidentied factors, causing a cycle
of perpetuation of symptoms.
The diagnosis: What is wrong with her?
Symptoms or signs of organic disease need assessment before
considering functional pain. The presence of red ag symptoms
should alert the clinician to the possibility of inammatory bowel
disease (IBD), coeliac disease or other organic causes of abdom-
inal pain (table 3). A characteristic history, in the absence of con-
cerning ndings, suggests a functional GI condition (table 1).
The history should include assessment of physical symptoms
including characteristics, timing, exacerbating and relieving
factors, and a detailed medical history. Previous abdominal
surgery and recent gastroenteritis-like illnesses are noteworthy.
A detailed family and social history is relevant, focusing on rela-
tionships, school performance and personal goal-setting in aca-
demic and non-academic settings, such as sports and music.
The initial assessment is key to develop a trusting relationship
to encourage children to verbalise their symptoms. One can ask
a younger child, If I was to grant you three wishes, what would
they be?This may elucidate the signicance of the condition
for the child, or reveal a trigger, including worries about the
Although primarily a GI disorder, children with FAP syn-
drome frequently report non-GI symptoms, for example, head-
ache, limb pains and dizziness.
These symptoms must be
assessed, but if functional, may respond to the same strategies in
managing FAP.
Investigations: Surely she needs tests?
Any suspicion of organic disease identied through history and
examination should guide initial investigations.
Figure 1 A biopsychosocial model of
pain: for use with parents and
Brown LK, et al.Arch Dis Child 2015;0:17. doi:10.1136/archdischild-2014-306426 3
Review on March 11, 2016 - Published by from
In the absence of red ags, investigations should be focused
and one-stop, and accompanied by discussion of the low likeli-
hood of identifying an organic cause (see table 4). All children
with RAP should have a basic blood screen including testing for
coeliac disease. If there is suspicion of IBD, faecal calprotectin
may be useful (sensitivity 0.97; 95% CI 0.92 to 0.99; specicity
0.70; 95% 0.59 to 0.79) for diagnosing IBD, with only 2%
false negative result.
Other blood tests have limited value unless clinically indi-
cated. One study of 157 children comparing well children and
those with functional symptoms (N=157) found no difference
in erythrocyte sedimentation rate (median in pain-free children
3 mm/h vs 5 mm/h in the functional group).
Leucocyte count
was similar in the functional and pain-free group (mean values:
functional group 7.4×10
/L, vs pain-free group 8.3×10
p>0.05: not signicant). Prevalence of stool parasites was 6/87
(7%) in the functional group and 9/70 (13%) in healthy con-
trols (p=0.28: not signicant).
Parents may request a scan; however, there is no evidence to
suggest that ultrasound of abdomen/pelvis, in the absence of red
ag symptoms, has a signicant yield of organic disease unless
there are specic pointers. Ultrasound can be useful to assess the
gallbladder/biliary tree and for thickened bowel loops if con-
cerning signs or symptoms are present.
Parents can associate negative tests with an inability to dis-
cover the underlying disease process.
Clinical bottom line
In children with functional symptoms, investigations should be
limited unless there are specic pointers in the history and
examination. Performing more tests on children with functional
symptoms that does not improve the identication of organic
disease invites further anxiety.
Management: Can you make her better?
Parents usually believe the pain is organic. When a functional
disorder is suspected, it should be shared with the family to
allow the family to engage in management at the point of diag-
nosis. The key then lies in explaining the biopsychosocial model
of FAP tailored to the educational and developmental level of
the patient. Age-appropriate analogies such as comparing the
pain to an oversensitive burglar alarmcan help. A normal
burglar alarm will detect humans only; analogous to normal
GI sensations such as satiety from a large meal. However, some-
times a burglar alarm can be oversensitiveand alarm with
movements of pets or insects, equivalent to pain from normal
gut movements. Teenagers with higher understanding may
prefer the concept of nociception and visceral and central
hypersensitivity (table 5).
Counselling parents that FAP is common, that the long-term
prognosis is favourable and that FAP does not lead to severe
illness can help to alleviate anxiety. The child and familys
approach has the greatest impact on the course of the
Techniques to alleviate abdominal pain were compared in one
useful study.
Parents were trained to respond to the child in
pain with either attention, distraction or no instruction.
Symptom complaints markedly rose in the attention subgroup
(weighted SD d=1.98 vs 0.75) compared with the No instruc-
tion condition, and the Distraction group had a sizeable
improvement in symptoms compared with no instruction
(d=0.99 vs 1.6).
Table 4 Suggested initial investigations to consider in ruling out organic disease
Blood tests Full blood count, urea and electrolytes, C reactive protein, erythrocyte sedimentation rate, liver function test, amylase/lipase
Coeliac antibody screen: total immunoglobulin A and tissue transglutaminase/endomysial antibody status
Consider IgE+ food allergy panel (RAST to egg, wheat, milk, soya) only if specific pointers in history/family history
Stool M,C+S and O,C+P
Faecal calprotectin if there are suspicions regarding inflammatory bowel disease
Consider Helicobacter testing if there are predominant upper gastrointestinal symptoms and visiting high prevalence areas
Urine Dipstix test
Imaging Ultrasound
Abdominal X-ray
Bowel transit studies
Barium radiology
Gastroscopy and Ileocolonoscopy*
*All low yield without specific pointers. RAST, radioallergosorbent test.
Table 3 Red flag symptoms and signs in children with recurrent abdominal pain
Symptoms and key features in the history Red flag signs of gastrointestinal disease
Involuntary weight loss Slowing of linear growth
Chronic severe diarrhoea Clubbing
Gastrointestinal blood loss Mouth ulcers
Gynaecological symptoms Abdominal masses
Family history of inflammatory bowel disease/coeliac disease Pain radiating through to the back (pancreatitis) or loins (renal pain)
Night-time waking Anorexia/delayed puberty
Significant vomiting (especially if bilious) Hypertension/tachycardia
Urinary symptoms Perineal changes (tags/fistulae)
4 Brown LK, et al.Arch Dis Child 2015;0:17. doi:10.1136/archdischild-2014-306426
Review on March 11, 2016 - Published by from
Psychological therapies
The strongest evidence for effective therapy for FAP comes
from psychological methods (see table 6). These aim to reduce
psychological stressors driving the braingut axis in causing
symptoms. Cognitive-behavioural therapy, hypnotherapy, family
therapy and other similar methods are helpful: a recent
Cochrane review looked at psychological therapies for pain
management in children (37 studies, n=1938 children) and
described benecial effects for non-headache pain, including
abdominal pain (7 studies).
These methods had some effect in
reducing pain (ve studies: 357 participants: standard mean
difference (SMD) 0.51 (0.8 to 0.22)), which was statistic-
ally signicant, with moderate quality evidence (GRADE cri-
teria). The impact on mood was smaller (three studies: 292
children: SMD 0.09 (95% CI 0.32 to 0.14)) and not statistic-
ally signicant (z=0.74, p>0.05).
Explaining the relevance of psychological techniques is key
to help parents and children buy-in, and also to support the
referral for mental health psychology input. The analogy of
childbirth can help to explain how effective psychological strat-
egies can mitigate pain perception; by using breathing exercises/
visualisation pain scores and overall experiential measures can
be improved.
A 6-week course of twice-weekly yoga in 51 adolescents with
IBS (1417 years) showed 44% of adolescents reported signi-
cantly reduced pain; this, however, was not sustained at
2-month follow-up.
Clinical bottom line
Parents should reward positive coping behaviours and under-
stand their role in managing pain. Parental reinforcement or
hypervigilance for symptoms can worsen pain. Distraction strat-
egies help to reduce pain perception. Psychological therapies,
when explained appropriately, have the best evidence of efcacy.
Can you give her some medicine?
There is limited evidence for effective medications for functional
symptoms, and the emphasis remains on avoiding a medicine-
based therapeutic approach. Options include famotidine for
Table 5 How to approach the management of a child with
recurrent abdominal pain (RAP)
1 Explain the biopsychosocial theory of RAP: the pain is real
2 Offer reassurance: it is not life threatening, 2/3 improve
3 Explain aim is to manage pain and optimise daily function
4 Give suggestions of lifestyle changes: including dietary triggers, relationship
building, family discourse
5 Discuss coping strategies such as distraction, deep breathing
6 Refer to psychology team if high functional disability
7 Encourage graded return to school: liaise with school
8 Consider discussion or referral to child and adolescent mental health
services (CAMHS) if anxiety and depression is a significant feature inhibiting
potential rehabilitation
9 Arrange to review after the above have been addressed
10 Consider medication: only if indicated (see table 5)
Table 6 Evidence-based treatments for recurrent abdominal pain (RAP)
Condition and treatment studied Trial description Conclusion Side effects
antagonists for Functional dyspepsia 1 RCT (n=25) showed subjective improvements but no objective reduction in pain
Uncertain None significant
Lactose-free diet for RAP Cochrane review of 2 RCTs comparing lactose-containing and lactose-free diets (38
14 and 11 children in each group respectively reported increased pain.
No paired comparisons undertaken. Difference non-significant
Benefit unlikely Not evaluated
Psychological therapies including CBT
and hypnotherapy for functional pain
Cochrane review of 9 RCTs (709 patients) comparing CBT to waiting or standard
medical care.
49% of children who received CBT reported less pain compared with
17% of children who did not receive a psychological therapy. SMD in pain scores
between the group receiving the psychological therapy, and controls was SMD 0.51
(0.8 to 0.22) at end of treatment (p=0.0002)
Systematic review of hypnotherapy: three studies (108 patients).[58] Pain scores
(p<0.05), school absenteeism (p=0.02) and long-term outlook were significantly
improved: in 1 long-term study: At 1 year, 85% remained in remission vs 25% of
controls. At 5 years 68% children were in remission vs controls: (68% vs 20%,
Beneficial None
Probiotics for IBS or functional pain Cochrane meta-analysis of Lactobacillus:
no significant symptom improvements
(3 trials: 168 children). The pooled OR for improvement of symptoms was 1.17 (95% CI
0.62 to 2.21).
Also: 1 placebo-controlled multicentre RCT of 141 children given Lactobacillus GG.
Lactobacillus GG caused significant reduction of frequency (p<0.01) and severity
(p<0.01) of abdominal pain. These differences were significant at wk 16 (p<0.02 and
p<0.001, respectively)
1 placebo-controlled RCT of VSL3 in 59 children with IBS:
VSL3 was significantly
superior to placebo for reducing pain/discomfort, bloating and impact on family
(p<0.05). No significant difference was found (p=0.06) in stool pattern
Some evidence of
Added fibre for IBS Cochrane review of 2 RCTs in 92 patients:
no significant improvement. The pooled OR
for improvement in the frequency of abdominal pain with fibre was 1.26 (95% CI 0.25
to 6.29)
Benefit unlikely None
Peppermint oil for IBS 1 RCT of peppermint oil in 42 children (71% improved vs 41% improved on placebo
(relative risk 1.67, 95% CI 0.95 to 2.93)
Likely beneficial Not evaluated
Pizotifen for abdominal migraine 1 placebo-controlled crossover RCT in 14 children for 1 month (mean 8.21 more
pain-free days, 95% CI 2.93 to 13.48)
Likely beneficial Drowsiness,
weight gain
There is no current paediatric evidence for analgesics, ondansetron, antispasmodics, tricyclics or other agents for neuropathic pain, for example, gabapentin.
CBT, cognitive-behavioural therapy; IBS, irritable bowel syndrome; RCT, randomised controlled trial; SMD, standard mean difference.
Brown LK, et al.Arch Dis Child 2015;0:17. doi:10.1136/archdischild-2014-306426 5
Review on March 11, 2016 - Published by from
epigastric pain, peppermint oil capsules for IBS and pizotifen for
abdominal migraine. Several other drugs have been trialled in
small groups and have not demonstrated signicant relief or cure
(table 6). In targeting the psychological elements of FAP, psycho-
tropic medications have been investigated; however, there is no
evidence of efcacy and clinicians should be wary of potential
side effects.
Although patients may enquire about dietary exclusions to alle-
viate symptoms, little evidence exists for a particular diet. A
Cochrane review in 2009 found no signicant benetfrom
lactose-free diets or supplemental bre and a lack of quality evi-
However, recent evidence that Lactobacillus rhamno-
sus GG taken three times daily has a modest clinical effect in
reducing symptoms for patients with IBS, but not for FAP.
may be offered to patients as a 1-month trial for IBS.
Avoiding the classical 4 Ctrigger foods of cheese, chocolate,
citrus fruits and caffeinated drinks may reduce the frequency of
abdominal migraines. This is based on the effect of tyramine,
phenylethylamine, histamine, nitrites and caffeine on migraine.
A food diary may help to ascertain which foods precipitate
painful episodes.
A recent study showed that eating seven pieces of fresh fruit
and vegetable benets general health.
Of 965 children, FAP
occurred in 20% of children who ate more than three pieces of
fruit per week, and in 40% of those who ate no pieces of fruit
per week.
As well as maintaining regular exercise, obesity was
an independent risk factor for pain syndromes in children in
this study (33.3% vs 22.5%).
For children with IBS a diet low in bre, increasing the
bre content can help, and a diet sheet can support families
choices. The fermentable oligosaccharides, disaccharides,
monosaccharides and polyols diet is sometimes recommended
for adults with IBS; however, there is little paediatric data
and requires a healthcare professional with dietary expertise
to provide support.
Is there anything else we can do to help?
Accept that the pain is real. Exercise and outdoor play is an
effective distraction. By the time of paediatric assessment,
school attendance is often affected, causing additional stress.
Graded return to school can be more practical than an immedi-
ate return to a normal school timetable, especially with support
from regular teachers.
Clinical bottom line
The evidence base for medications is poor. Give families prac-
tical strategies to help improve function, such as exercise pro-
grammes and graded school reintroduction.
Prognosis Will she get better?
Patients and parents can be positively reassured that FAP
remains likely to improve with age. This approach helps to miti-
gate parental concerns regarding development of more severe
symptoms. A meta-analysis of follow-up data (5 years) found
that 29.1% of children have persistent pain (95% CI 28.1 to
In a larger study with long term follow-up (to 36 years
old), only 7% of those who had FAP as children had persistent
abdominal symptoms.
However, a higher proportion of chil-
dren may subsequently develop disease: a recent study of
>268 000 children admitted with non-specic abdominal pain
had a 4× relative risk of subsequent diagnosis of Crohns
disease and 3× risk of coeliac disease up to 10 years later
compared with a control group of children admitted with unre-
lated conditions.
If pain persists into adulthood, the common-
est label given is IBS. Overall, children with functional
dyspepsia have a moderately better outcome over a 1-year
follow-up compared with other functional GI conditions.
Known factors inuencing persistence of symptoms:
patients who struggle to effectively employ coping
hospitalisation due to pain or reports of very high pain
non-GI symptoms;
obese children (p<0.0017, over 1215 months follow-up).
The familial interaction with medical services may potentially
affect outcome. In a study of 23 children, pain lasting over
12 months was more likely in children of families who refused
to engage in psychological therapy (relative risk 4.55, p<0.05,
95% CI 1.19 to 17.35), who saw three or more consultants
(relative risk 7, p<0.001, 95% CI 1.94 to 25.26), who lodged a
complaint to hospital management ( p<0.05, relative risk 3.25,
95% CI 1.11 to 9.48) or had lack of insight into the psycho-
social aspects of the condition (p<0.001, relative risk 7.49,
95% CI 1.14 to 49.56).
This highlights the importance of
managing these familiesexpectations and may also indicate
raised family stress levels.
Clinical bottom line
Often, these children can have intermittent exacerbations, but
generally do improve with time, although this can be adversely
affected if parents struggle to accept the functional nature of the
symptoms. Most improve but several factors predispose to
symptom entrenchment including failure of parents to accept
functional nature of symptoms and who struggle to cope with
symptoms, hospitalisation and obesity.
Managing FAP requires skilled history-taking and examination,
coupled with communication skills that allow the clinician to
gain an understanding of the childs pain, how multiple factors
inuence it and how to share this with the family. Functional
symptoms are experienced by most children at some point, but
their outlook depends on their personality, coping mechanisms
and support network; and the ability of parents to cope and
modify their own behaviour; as well as the clinicians ability to
adequately explain and engage the family. Clinicians should
reassess if new red ag symptoms occur and reinvestigate if
Contributors LB and MT wrote the initial draft. LB, RMB and MT edited this ready
for publication. MT acts as guarantor for the submission.
Competing interests None declared.
Provenance and peer review Commissioned; externally peer reviewed.
1 Apley J, Naish N. Recurrent abdominal pains: a eld survey of 1,000 school
children. Arch Dis Child 1958;33:16570.
2 Oster J. Recurrent abdominal pain, headache and limb pains in children and
adolescents. Pediatrics 1972;50:42936.
3 Ramchandani PG, Hotopf M, Sandhu B, et al. The epidemiology of recurrent
abdominal pain from 2 to 6 years of age: results of a large, population-based
study. Pediatrics 2005;116:46.
4 Rasquin A, Di Lorenzo C, Forbes D et al. Childhood functional gastrointestinal
disorders: child/adolescent. Gastroenterology 2006;130:152737.
5 Shulman RJ, Eakin MN, Jarrett M, et al. Characteristics of pain and stooling in
children with recurrent abdominal pain. J Pediatr Gastroenterol Nutr
6 Brown LK, et al.Arch Dis Child 2015;0:17. doi:10.1136/archdischild-2014-306426
Review on March 11, 2016 - Published by from
6 Tanaka Y, Kanazawa M, Fukudo S, et al. Biopsychosocial model of irritable bowel
syndrome. J Neurogastroenterol Motility 2011;17:1319.
7 Faure C, Wieckowska A. Somatic referral of visceral sensations and rectal sensory
threshold for pain in children with functional gastrointestinal disorders. J Pediatr
8 Saps M, Di Lorenzo C. Pharmacotherapy for functional gastrointestinal disorders in
children. J Pediatr Gastroenterol Nutr 2009;48(Suppl 2):S1013.
9 Logan DE, Scharff L. Relationships between family and parent characteristics and
functional abilities in children with recurrent pain syndromes: an investigation of
moderating effects on the pathway from pain to disability. J Pediatr Psychol
10 Locke GR III, Zinsmeister AR, Talley NJ, et al. Familial association in adults with
functional gastrointestinal disorders. Mayo Clin Proc 2000;75:90712.
11 Pace F, Zuin G, Di Gianomo S, et al. Family history of irritable bowel syndrome is
the major determinant of persistent abdominal complaints in young adults with a
history of pediatric recurrent abdominal pain. World J Gastroenterol
12 Levy RL, Jones KR, Whitehead WE, et al. Irritable bowel syndrome in twins: heredity
and social learning both contribute to etiology. Gastroenterology
13 Lembo A, Zaman M, Jones M, et al.Inuence of genetics on irritable bowel
syndrome, gastro-oesophageal reux and dyspepsia: a twin study. Aliment
Pharmacol Ther 2007;25:134350.
14 van Tilburg M, Runyan D, Zolotor A, et al. Unexplained gastrointestinal symptoms
after abuse in a prospective study of children at risk for abuse and neglect. Ann
Fam Med 2010;8:13440.
15 Garber J, Zeman J, Walker LS. Recurrent abdominal pain in children: psychiatric
diagnoses and parental psychopathology. J Am Acad Child Adoles Psychiatry
16 Saps M, Seshadri R, Sztainberg M, et al. A prospective school-based study of
abdominal pain and other common somatic complaints in children. J Pediatr
17 Machnes-Maayan D, Elazar M, Apter A, et al. Screening for psychiatric comorbidity
in children with recurrent headache or recurrent abdominal pain. Pediatr Neurol
18 Cunningham NR, Cohen MB, Farrell MK, et al. Concordant parentchild reports of
anxiety predict impairment in youth with functional abdominal pain. J Pediatr
Gastroenterol Nutr 2015;60:31217.
19 Walker LS, Smith CA, Garber J, et al. Appraisal and coping with daily stressors by
pediatric patients with chronic abdominal pain. J Pediatr Psychol 2007;32:
20 van Tilburg MAL, Chitkara DK, Palsson OS, et al. Parental worries and beliefs about
abdoominal pain. J Pediatr Gastroenterol Nutr 2009;48:31117.
21 Ramchandani PG, Fazel M, Stein A, et al. The impact of recurrent abdominal pain:
predictors of outcome in a large population cohort. Acta Paediatr
22 Williams N, Jackson D, Lambert PC, et al. Incidence of non-specic abdominal pain
in children during school term: population survey based on discharge diagnoses.
BMJ 1999;318:1455.
23 Morenas R, Tighe MP Brown L, Beattie RM. Recurrent abdominal pain: a BMJ
Learning module. 2014.
24 Dengler-Crish CM, Horst SN, Walker LS. Somatic complaints in childhood
functional abdominal pain are associated with functional gastrointestinal
disorders in adolescence and adulthood. J Pediatr Gastroenterol Nutr
25 Degraeuwe PLJ, Beld MPA, Ashorn M, et al. Faecal calprotectin in suspected
paediatric inammatory bowel disease: an individual patient data meta-analysis.
J Pediatr Gastroenterol Nutr 2015;60:33946.
26 Soon GS, Saunders N, Ipp M, et al. Community-based case-control study of
childhood chronic abdominal pain: role of selected laboratory investigations.
J Pediatr Gastroenterol Nutr 2007;44:5246.
27 Gieteling M, Bierma-Zeinstra SM, Passchier J, et al. Prognosis of chronic or recurrent
abdominal pain in children. J Pediatr Gastroenterol Nutr 2008;47:31626.
28 Walker LS, Williams SE, Smith CA, et al. Parent attention versus distraction: impact
on symptom complaints by children with and without chronic functional abdominal
pain. Pain 2006;122:4352.
29 Eccleston C, Palermo TM, Williams ACDC, et al. Psychological therapies for the
management of chronic and recurrent pain in children and adolescents. Cochrane
Database Syst Rev 2012;12:CD003968.
30 Evans S, Lung KC, Seidman LC, et al. Iyengar yoga for adolescents and young adults
with irritable bowel syndrome. J Pediatr Gastroenterol Nutr 2009;59:24453.
31 Huertas-Ceballos A, Logan S, Bennett C, et al. Pharmacological interventions for
recurrent abdominal pain (RAP) and irritable bowel syndrome (IBS) in childhood.
Cochrane Database Syst Reviews 2008;23:CD003017.
32 Huertas-Ceballos A, Logan S, Bennett C, et al. Dietary interventions for recurrent
abdominal pain (RAP) and irritable bowel syndrome (IBS) in childhood. Cochrane
Database Syst Reviews 2009;21:CD003019.
33 Francavilla R, Miniello V, Magistà AM, et al. A randomized controlled trial of
lactobacillus GG in children with functional abdominal pain. Pediatrics 2010;126:
34 Millichap JG, Yee MM. The diet factor in pediatric and adolescent migraine.
Pediatric Neurology 2003;28:915.
35 Oyebode O, Gordon-Dseagu V, Walker A, et al. Fruit and vegetable consumption
and all-cause, cancer and CVD mortality: analysis of Health Survey for England
data. J Epidemiol Community Health 2014;68:85662.
36 Malaty HM, Abudayyeh S, Fraley K, et al. Recurrent abdominal pain in school
children: effect of obesity and diet. Acta Paediatrica 2007;96: 5726.
37 Hookway C, Buckner S, Crosland P, et al. Irritable bowel syndrome in adults in
primary care: summary of updated NICE guidance. BMJ 2015;350:h701.
38 Hotopf M, Carr S, Mayou R, et al. Why do children have chronic abdominal pain,
and what happens to them when they grow up? Population based cohort study.
BMJ 1998;316:1196200.
39 Lisman-van Leeuwen Y, Spee LA, Benninga MA, et al. Prognosis of abdominal pain
in children in primary carea prospective cohort study. Ann Fam Med
40 Thornton G, Goldacre M, Howarth L, et al. Diagnostic outcomes following
childhood non-specic abdominal pain: a record-linkage study. Arch Dis Child
2015; Published Online First: 28 Jul 2015. doi:10.1136/archdischild-2015-308198
41 Schulte IE, Petermann F, Noeker M. Functional abdominal pain in childhood: from
etiology to maladaptation. Psychother Psychosom 2010;79:7386.
42 Bonilla S, Wang D, Saps M. Obesity predicts persistence of pain in children with
functional gastrointestinal disorders. Int J Obes (Lond) 2011;35:51721.
43 Rutten JM, Benninga MA, Vlieger AM. IBS and FAP(S) in children: a comparison of
psychological and clinical characteristics. J Pediatr Gastroenterol Nutr
44 Lindley KJ, Glaser D, Milla PJ. Consumerism in healthcare can be detrimental to
child health: lessons from children with functional abdominal pain. Arch Dis Child
45 Levy RL, Whitehead WE, Von Korff MR et al. Intergenerational transmission of
gastrointestinal illness behavior. Am J Gastroenterol 2000;95:4516.
Brown LK, et al.Arch Dis Child 2015;0:17. doi:10.1136/archdischild-2014-306426 7
Review on March 11, 2016 - Published by from
abdominal pain in children
Practical management of functional
L K Brown, R M Beattie and M P Tighe
published online December 23, 2015Arch Dis Child
Updated information and services can be found at:
These include:
This article cites 43 articles, 13 of which you can access for free at:
Email alerting box at the top right corner of the online article.
Receive free email alerts when new articles cite this article. Sign up in the
Topic Articles on similar topics can be found in the following collections
(761)Oncology (582)Pain (neurology)
To request permissions go to:
To order reprints go to:
To subscribe to BMJ go to: on March 11, 2016 - Published by from
... In economic terms, for instance, FAP and irritable bowel syndrome are estimated to annually cost about e2,500 per person in the Netherlands [10]. As for chronic pain in general [11], a biopsychosocial perspective has been proposed to better understand and conceptualize FAP [12,13]. In this direction, the literature confirms that interventions from a biopsychosocial perspective (usually including the whole family) are the most effective [14][15][16]. ...
... However, apart from suffering, some families also expressed feeling relief after learning that their child did not have a severe illness or after they had accepted the situation. These results are congruent with studies suggesting that reassurance can help children with FAP and their parents [12,42]. In addition to their feelings, pain also affected families' behaviors and social activities. ...
... Stress and stressful situations were also frequently mentioned as pain triggers, especially by parents who had completed the online psychosocial intervention. This recognition of the triggering effect of stress or stressful situations is consistent with studies suggesting that stress is a contributing factor to abdominal pain [12,13]. Mothers in the study by Smart and Cottrell [18] reported that psychological factors played a role in pain. ...
Objective: Although functional abdominal pain (FAP) is one of the most common pain problems in children, there is a lack of qualitative studies on this topic. Our aim was to increase knowledge in this field by testing an innovative written narrative methodology designed to approach the experiences of children with FAP and their parents. Methods: We analyzed the FAP experiences of 39 families who completed a written narrative task (children and parents separately). Some of the families (N = 20) had previously completed an online psychosocial intervention, whereas others had not, because a complementary objective was to explore possible differences between parent and child narratives, and between those who had and had not completed the intervention. Results: Families wrote about abdominal pain (characteristics, triggers, pain consequences, and coping strategies), their well-being, the diagnostic process, future expectations, and the positive effects of an online psychosocial intervention. Children tended to mention pain characteristics more, whereas parents tended to write more about triggers and the diagnostic process. Conclusions: A written narrative methodology was found to be a useful approach for understanding families' experiences. Results confirmed that FAP affects families at the emotional, behavioral, and social levels and that an online psychosocial intervention can help families.
... Currently, paediatric and adult functional gastrointestinal disorders are described as separate but overlapping diseases within the Rome IV criteria [51]. Irritable bowel disease (IBS) represents 65% of the diagnosis, followed by FAP, abdominal migraine, functional dyspepsia, functional constipation, and diarrhoea [52]. Our literature analysis reviewed the most frequent FGIDs diagnosed in clinical practice, such as IBS, functional abdominal pain (FAP), functional dyspepsia (FD) and functional constipation (FC) and their association with MD. ...
... As regards functional abdominal pain and functional constipation, in the literature reviewed there were no high-quality studies which could identify an effective dietary scheme, especially for children [58]. One of the reasons might be related to the multifactorial pathogenesis of these diseases, which make it difficult to individuate an efficacious dietary pattern [52,59]. Nevertheless, these patients still frequently seek information about how they can change their diet scheme in order to improve their quality of life and decrease their symptoms [58,59]. ...
Full-text available
The Mediterranean diet is considered one of the healthiest dietary patterns worldwide, thanks to a combination of foods rich mainly in antioxidants and anti-inflammatory nutrients. Many studies have demonstrated a strong relationship between the Mediterranean diet and some chronic gastrointestinal diseases. The aim of this narrative review was to analyse the role of the Mediterranean diet in several gastrointestinal diseases, so as to give a useful overview on its effectiveness in the prevention and management of these disorders.
... For almost 90% of children with chronic abdominal pain, no explanatory organic cause can be identified [15], and psychosocial factors contribute to the development and maintenance of the disease [16]. The predisposing factors and pathophysiological mechanisms of FAPDs include visceral hypersensitivity, altered gastrointestinal motility, and changes in intestinal microbiota, as well as stressful events [3,17], mental health issues, and negative experiences, such as bullying [18]. These children are likely to have poor coping strategies for stressful situations [19]. ...
... Physical activity has been shown to be effective in the practical management of FAPDs [18] by distracting from the pain and improving function. Unfortunately, levels of physical activity among young girls is alarmingly low, which calls for action [28]. ...
Background Functional abdominal pain disorders (FAPDs) affect many children worldwide, predominantly girls, and cause considerable long-term negative consequences for individuals and society. Evidence-based and cost-effective treatments are therefore strongly needed. Physical activity has shown promising effects in the practical management of FAPDs. Dance and yoga are both popular activities that have been shown to provide significant psychological and pain-related benefits with minimal risk. The activities complement each other, in that dance involves dynamic, rhythmic physical activity, while yoga enhances relaxation and focus. Objective This study aims to evaluate the effects of a dance and yoga intervention among girls aged 9 to 13 years with FAPDs. Methods The study is a prospective randomized controlled trial among girls aged 9 to 13 years with functional abdominal pain, irritable bowel syndrome, or both. The target sample size was 150 girls randomized into 2 arms: an intervention arm that receives dance and yoga sessions twice weekly for 8 months and a control arm that receives standard care. Outcomes will be measured at baseline and after 4, 8, 12, and 24 months, and long-term follow-up will be conducted 5 years from baseline. Questionnaires, interviews, and biomarker measures, such as cortisol in saliva and fecal microbiota, will be used. The primary outcome is the proportion of girls in each group with reduced pain, as measured by the faces pain scale-revised in a pain diary, immediately after the intervention. Secondary outcomes are gastrointestinal symptoms, general health, mental health, stress, and physical activity. The study also includes qualitative evaluations and health economic analyses. This study was approved by the Regional Ethical Review Board in Uppsala (No. 2016/082 1-2). Results Data collection began in October 2016. The intervention has been performed in 3 periods from 2016 through 2019. The final 5-year follow-up is anticipated to be completed by fall 2023. Conclusions Cost-effective and easily accessible interventions are warranted to reduce the negative consequences arising from FAPDs in young girls. Physical activity is an effective strategy, but intervention studies are needed to better understand what types of activities facilitate regular participation in this target group. The Just in TIME (Try, Identify, Move, and Enjoy) study will provide insights regarding the effectiveness of dance and yoga and is anticipated to contribute to the challenging work of reducing the burden of FAPDs for young girls. Trial Registration (NCT02920268); International Registered Report Identifier (IRRID) DERR1-10.2196/19748
... Chronic or functional abdominal pain (FAP) is one of the most common physical complaints in children [1][2][3][4][5], causing prolonged absence from kindergarten and school, parental anxiety, frequent medical referrals and numerous diagnostic procedures that impose significant costs on the family and the health system. The origin of abdominal pain can be organic or functional. ...
... Social, psychological factors and life events (such as the death of parents in childhood, divorce or separation of parents, change of school, examinations, etc.) have been cited as possible reasons for FAP in children [2,5,9]. Some studies suggested that these factors are associated with GI motility [2] and also there is some evidence regarding the association of anxiety and depressive disorders with irritable bowel syndrome and ulcerative colitis [10]. ...
Full-text available
Background: Gastrointestinal (GI) disorders are ranked first amongst medical diseases as a trigger of requests for mental health counselling. Child abuse has been regarded as one of the main causes of the development of functional abdominal pain (FAP) in children. This study aimed, therefore, to compare the prevalence of child abuse experience among two groups of patients with and without FAP. Methods: A case-control study of children in Arak, Iran, in which experience of child abuse was compared in children with (n = 100) and without functional abdominal pain (n = 100). Three categories of child abuse - emotional abuse, physical abuse, and neglect - were assessed using the Child Abuse Questionnaire. The data were analyzed using Stata software. Results: After adjusting for potential confounders, there were group differences in emotional abuse (96% vs. 81%, aOR = 5.13, 95% CI: 1.3-20.3, p = 0.017), neglect (28% vs. 8%, aOR = 4.27, 95% CI: 1.8-11.8, p = 0.001) and total child abuse score (98% vs. 84%, aOR = 8.2, 95% CI: 1.5-43.8, p = 0.014) but not in physical abuse (57% vs. 46%, aOR = 1.47, 95% CI: 0.81-2.60, p = 0.728). Conclusions: As the prevalence of child abuse is higher in patients with FAP, child abuse appears to be related to the occurrence of FAP in children. However, the results of this study cannot be generalized to Iranian society generally and further longitudinal studies are recommended.
... In addition, many new psychological interventions like acceptance and commitment therapy as well as mindfulness are under development and research (13). Physical activity has shown beneficial effects in the practical management of FAPDs (14), by improving function and distraction from pain. Dance is one of the most popular physical activities among girls (15) and has been shown to improve both physiological (16) and psychological (17,18) health in youths. ...
Introduction Functional abdominal pain disorders (FAPDs) are common among girls and has been associated with stress. Cortisol is one of the major stress hormones. Dance and yoga have been shown to reduce abdominal pain among girls with FAPDs. Aim To investigate the effect of an 8-month intervention with dance and yoga on cortisol levels in saliva among girls with FAPDs. Methods A total of 121 girls aged 9–13 years with irritable bowel syndrome (IBS) or functional abdominal pain were included in the study. Participants were randomized into an intervention group and a control group. The intervention group attended a combined dance and yoga session twice a week for 8 months. Saliva samples were collected during 1 day, in the morning and evening, at baseline, and at 4 and 8 months. Subjective pain and stress were assessed as well. Results No significant effects on saliva cortisol levels between groups were observed after completion of the intervention at 8 months. However, evening cortisol and evening/morning quotient were significantly reduced at 4 months in the intervention group compared to the control group ( p = 0.01, p = 0.004). There was no association between cortisol quota and pain or stress. Conclusion Improvements in cortisol levels were seen in the intervention group at 4 months but did not persist until the end of the study. This indicates that dance and yoga could have a stress-reducing effect during the ongoing intervention.
... We can speculate that although the children were not exceedingly anxious, the fact that their parents had anxiety might have amplified their perception of pain. One of the hallmarks of care of pediatric patients with functional abdominal pain is reassurance by the caregivers [26] . The alternative explanation would be that their child's disease caused anxiety in the parent, and that anxiety persisted because of persisting symptoms. ...
Full-text available
Background: Chronic abdominal pain occurs frequently in pediatric patients with inflammatory bowel disease (IBD) in remission. Aims: To assess the prevalence and factors associated with Functional Abdominal Pain Disorders among IBD children in remission (IBD-FAPD). Methods: Patients with IBD for > 1 year, in clinical remission for ≥ 3 months were recruited from a National IBD network. IBD-FAPDs were assessed using the Rome III questionnaire criteria. Patient- or parent- reported outcomes were assessed. Results: Among 102 included patients, 57 (56%) were boys, mean age (DS) was 15.0 (± 2.0) years and 75 (74%) had Crohn's disease. Twenty-two patients (22%) had at least one Functional Gastrointestinal Disorder among which 17 had at least one IBD-FAPD. Past severity of disease or treatments received and level of remission were not significantly associated with IBD-FAPD. Patients with IBD-FAPD reported more fatigue (peds-FACIT-F: 35.9 ± 9.8 vs. 43.0 ± 6.9, p = 0.01) and a lower HR-QoL (IMPACT III: 76.5 ± 9.6 vs. 81.6 ± 9.2, p = 0.04) than patients without FAPD, and their parents had higher levels of State and Trait anxiety than the other parents. Conclusions: Prevalence of IBD-FAPD was 17%. IBD-FAPD was not associated with past severity of disease, but with fatigue and lower HR-QoL.
... Each domain may be emphasized differently, depending on the individual child, the pain etiology, and the current evidence base. For example, if multidisciplinary management is framed as a combination of physical/physiological, pharmacological, and psychological therapeutic modalities [2], the current evidence bases for different conditions place greater emphasis on different modalities, e.g., physical therapies for pediatric complex regional pain syndrome (CRPS) [3], psychological therapies for functional abdominal pain [4], and pharmacological therapies for painful sickle cell crises [5]. ...
Full-text available
Objective To classify paediatric chronic pain referrals in Ireland using the ICD-11 classification. In addition, differences between primary and secondary pain groups were assessed. Methods Retrospective review of complex pain assessment forms completed at the time of initial attendance at paediatric chronic pain clinics in Dublin, Ireland. Patients were classified as having a chronic primary (CPP) or chronic secondary (CSP) pain condition as per ICD-11 classification. Secondary analysis of between-group and within-group differences between primary and secondary pain conditions was undertaken. Results Of 285 patients coded, 123 patients were designated as having a CPP condition (77% of which were assigned an adjunct parent code) and 162 patients as having a CSP condition (61% of which were assigned an adjunct parent code). Between-group comparisons found that the lowest reported pain scores were higher in CPP than CSP conditions. In the CSP group, there were stronger correlations between parental pain catastrophizing and pain intensity, school attendance, and pain interference with social activities, than in the CPP group. Conclusions The majority of children with both CPP and CSP were assigned multiple parent codes. There appears to be a gradient in the differences in biopsychosocial profile between CPP and CSP conditions. Additional field testing of the ICD-11 classification in paediatric chronic pain will be required.
... In children, the differentiation between common abdominal pain or transient diarrheal illness and IBD can be difficult and requires clinical expertise in conjunction with appropriate investigations. 22 This study has several limitations; we were unable to include patients who were referred with a possible diagnosis of PIBD whose endoscopy and histology were then normal. The study would benefit from these patients as a control group; however, they cannot reliably be identified from the patient record, leading to significant concerns over introducing bias. ...
Full-text available
Background Anti‐tumour necrosis factor‐α (anti‐TNF) therapy use has risen in paediatric‐onset inflammatory bowel disease (PIBD). Whether this has translated into preventing/delaying childhood surgery is uncertain. The Wessex PIBD cohort was analysed for trends in anti‐TNF‐therapy and surgery. Design All patients diagnosed with PIBD within Wessex from 1997 to 2017 were assessed. The prevalence of anti‐TNF‐therapy and yearly surgery rates (resection and perianal) during childhood (<18 years) were analysed (Pearson's correlation, multivariate regression, Fisher's exact). Results Eight‐hundred‐and‐twenty‐five children were included (498 Crohn's disease, 272 ulcerative colitis, 55 IBD‐unclassified), mean age at diagnosis 13.6 years (1.6‐17.6), 39.6% female. The prevalence of anti‐TNF‐treated patients increased from 5.1% to 27.1% (2007‐2017), P = 0.0001. Surgical resection‐rate fell (7.1%‐1.5%, P = 0.001), driven by a decrease in Crohn's disease resections (8.9%‐2.3%, P = 0.001). Perianal surgery and ulcerative colitis resection‐rates were unchanged. Time from diagnosis to resection increased (1.6‐2.8 years, P = 0.028) but mean age at resection was unchanged. Patients undergoing resections during childhood were diagnosed at a younger age in the most recent 5 years (2007‐2011 = 13.1 years, 2013‐2017 = 11.9 years, P = 0.014). Resection‐rate in anti‐TNF‐therapy treated (16.1%) or untreated (12.2%) was no different (P = 0.25). Patients started on anti‐TNF‐therapy <3 years post‐diagnosis (11.6%) vs later (28.6%) had a reduction in resections, P = 0.047. Anti‐TNF‐therapy prevalence was the only significant predictor of resection‐rate using multivariate regression (P = 0.011). Conclusion The prevalence of anti‐TNF‐therapy increased significantly, alongside a decrease in surgical resection‐rate. Patients diagnosed at younger ages still underwent surgery during childhood. Anti‐TNF‐therapy may reduce the need for surgical intervention in childhood, thereby influencing the natural history of PIBD.
Full-text available
Background: Recurrent abdominal pain (RAP) is a common complaint for children and can result in a significantly lower quality of life due to the extent it can interfere with normal life. RAP can also significantly impact the quality of life of parents. This study sought to qualitatively explore parents’ and children’s understanding and perceptions of the burden and impact of RAP. Methods: Semi-structured interviews were conducted with a sample of parent/child dyads or families (N = 5) engaging with a psychology service. Findings: The findings of the inductive thematic analysis revealed four emergent themes common to both parents and children: (1) Perception, understanding and identification of RAP, (2) Contributing factors, (3) Coping mechanisms/pain management strategies, and (4) Impact and burden of RAP. Conclusions: These findings have important clinical implications regarding the identification and management of RAP and may also contribute to improving communication between clinicians, parents and children by providing insight from multiple perspectives into how RAP is experienced.
Objectives Abdominal pain adversely impacts children with functional gastrointestinal disorders (FGIDs) or organic gastrointestinal disorders (OGIDs); findings are inconsistent regarding diagnosis and health-related quality of life (HRQoL). This study utilizes a positive psychology framework to understand the experience of youth with abdominal pain (i.e., do positive psychological factors, such as optimism and pain self-efficacy, relate to higher HRQoL). Consistent with a protective factor model of resilience, in which personal assets may serve as buffers between risk factors and negative outcomes, optimism and pain self-efficacy were examined as they relate to HRQoL in youth with abdominal pain. Specifically, exploratory moderational analyses examined a) if optimism and pain self-efficacy moderate the relation between pain and HRQoL, and b) whether diagnostic status moderated the relation between optimism/pain self-efficacy and HRQoL. Methods In a cross-sectional, observational study, youth (n = 98; Mage = 13, SD = 2.8) experiencing abdominal pain related to FGIDs or OGIDs and one of their parents participated. Measures included pain intensity, optimism, pain self-efficacy, and HRQoL. Analyses controlled for diagnosis, age, and gender. Results Higher pain and age related to lower HRQoL. Higher levels of optimism and pain self-efficacy associated with HRQoL beyond demographics. Optimism and pain self-efficacy did not moderate the relation between pain and HRQoL. Diagnostic status did not moderate the relation between optimism or pain self-efficacy and HRQoL. Discussion Our results suggest positive relations between positive psychological factors (optimism, pain self-efficacy) and HRQoL in youth with abdominal pain. Such factors could be further examined in intervention studies.
Full-text available
BACKGROUND: This is an update of the original Cochrane review first published in Issue 1, 2003, and previously updated in 2009 and 2012. Chronic pain affects many children, who report severe pain, disability, and distressed mood. Psychological therapies are emerging as effective interventions to treat children with chronic or recurrent pain. This update focuses specifically on psychological therapies delivered face-to-face, adds new randomised controlled trials (RCTs), and additional data from previously included trials. OBJECTIVES: There were three objectives to this review. First, to determine the effectiveness on clinical outcomes of pain severity, disability, depression, and anxiety of psychological therapy delivered face-to-face for chronic and recurrent pain in children and adolescents compared with active treatment, waiting-list, or standard medical care. Second, to evaluate the impact of psychological therapies on depression and anxiety, which were previously combined as 'mood'. Third, we assessed the risk of bias of the included studies and the quality of outcomes using the GRADE criteria. SEARCH METHODS: Searches were undertaken of CENTRAL, MEDLINE, EMBASE, and PsycINFO. We searched for further RCTs in the references of all identified studies, meta-analyses, and reviews. Trial registry databases were also searched. The date of most recent search was January 2014. SELECTION CRITERIA: RCTs with at least 10 participants in each arm post-treatment comparing psychological therapies with active treatment, standard medical care, or waiting-list control for children or adolescents with episodic, recurrent or persistent pain were eligible for inclusion. Only trials conducted in person (face-to-face) were considered. Studies that delivered treatment remotely were excluded from this update. DATA COLLECTION AND ANALYSIS: All included studies were analysed and the quality of outcomes were assessed. All treatments were combined into one class, psychological treatments. Pain conditions were split into headache and non-headache. Both conditions were assessed on four outcomes: pain, disability, depression, and anxiety. Data were extracted at two time points; post-treatment (immediately or the earliest data available following end of treatment) and at follow-up (between three and 12 months post-treatment). MAIN RESULTS: Seven papers were identified in the updated search. Of these papers, five presented new trials and two presented follow-up data for previously included trials. Five studies that were previously included in this review were excluded as therapy was delivered remotely. The review thus included a total of 37 studies. The total number of participants completing treatments was 2111. Twenty studies addressed treatments for headache (including migraine); nine for abdominal pain; two for mixed pain conditions including headache pain, two for fibromyalgia, two for recurrent abdominal pain or irritable bowel syndrome, and two for pain associated with sickle cell disease.Analyses revealed psychological therapies to be beneficial for children with chronic pain on seven outcomes. For headache pain, psychological therapies reduced pain post-treatment and at follow-up respectively (risk ratio (RR) 2.47, 95% confidence interval (CI) 1.97 to 3.09, z = 7.87, p < 0.01, number needed to treat to benefit (NNTB) = 2.94; RR 2.89, 95% CI 1.03 to 8.07, z = 2.02, p < 0.05, NNTB = 3.67). Psychological therapies also had a small beneficial effect at reducing disability in headache conditions post-treatment and at follow-up respectively (standardised mean difference (SMD) -0.49, 95% CI -0.74 to -0.24, z = 3.90, p < 0.01; SMD -0.46, 95% CI -0.78 to -0.13, z = 2.72, p < 0.01). No beneficial effect was found on depression post-treatment (SMD -0.18, 95% CI -0.49 to 0.14, z = 1.11, p > 0.05). At follow-up, only one study was eligible, therefore no analysis was possible and no conclusions can be drawn. Analyses revealed a small beneficial effect for anxiety post-treatment (SMD -0.33, 95% CI -0.61 to -0.04, z = 2.25, p < 0.05). However, this was not maintained at follow-up (SMD -0.28, 95% CI -1.00 to 0.45; z = 0.75, p > 0.05).Analyses revealed two beneficial effects of psychological treatment for children with non-headache pain. Pain was found to improve post-treatment (SMD -0.57, 95% CI -0.86 to -0.27, z = 3.74, p < 0.01), but not at follow-up (SMD -0.11, 95% CI -0.41 to 0.19, z = 0.73, p > 0.05). Psychological therapies also had a beneficial effect for disability post-treatment (SMD -0.45, 95% CI -0.71 to -0.19, z = 3.40, p < 0.01), but this was not maintained at follow-up (SMD -0.35, 95% CI -0.71 to 0.02, z = 1.87, p > 0.05). No effect was found for depression or anxiety post-treatment (SMD -0.07, 95% CI -0.30 to 0.17, z = 0.54, p > 0.05; SMD -0.15, 95% CI -0.36 to 0.07, z = 1.33, p > 0.05) or at follow-up (SMD 0.06, 95% CI -0.16 to 0.28, z = 0.53, p > 0.05; SMD 0.05, 95% CI -0.24 to 0.33, z = 0.32, p > 0.05). AUTHORS' CONCLUSIONS: Psychological treatments delivered face-to-face are effective in reducing pain intensity and disability for children and adolescents (<18 years) with headache, and therapeutic gains appear to be maintained, although this should be treated with caution for the disability outcome as only two studies could be included in the follow-up analysis. Psychological therapies are also beneficial at reducing anxiety post-treatment for headache. For non-headache conditions, psychological treatments were found to be beneficial for pain and disability post-treatment but these effects were not maintained at follow-up. There is limited evidence available to estimate the effects of psychological therapies on depression and anxiety for children and adolescents with headache and non-headache pain. The conclusions of this update replicate and add to those of the previous review which found that psychological therapies were effective in reducing pain intensity for children with headache and non-headache pain conditions, and these effects were maintained at follow-up for children with headache conditions.
Full-text available
Governments worldwide recommend daily consumption of fruit and vegetables. We examine whether this benefits health in the general population of England. Cox regression was used to estimate HRs and 95% CI for an association between fruit and vegetable consumption and all-cause, cancer and cardiovascular mortality, adjusting for age, sex, social class, education, BMI, alcohol consumption and physical activity, in 65 226 participants aged 35+ years in the 2001-2008 Health Surveys for England, annual surveys of nationally representative random samples of the non-institutionalised population of England linked to mortality data (median follow-up: 7.7 years). Fruit and vegetable consumption was associated with decreased all-cause mortality (adjusted HR for 7+ portions 0.67 (95% CI 0.58 to 0.78), reference category <1 portion). This association was more pronounced when excluding deaths within a year of baseline (0.58 (0.46 to 0.71)). Fruit and vegetable consumption was associated with reduced cancer (0.75 (0.59-0.96)) and cardiovascular mortality (0.69 (0.53 to 0.88)). Vegetables may have a stronger association with mortality than fruit (HR for 2 to 3 portions 0.81 (0.73 to 0.89) and 0.90 (0.82 to 0.98), respectively). Consumption of vegetables (0.85 (0.81 to 0.89) per portion) or salad (0.87 (0.82 to 0.92) per portion) were most protective, while frozen/canned fruit consumption was apparently associated with increased mortality (1.17 (1.07 to 1.28) per portion). A robust inverse association exists between fruit and vegetable consumption and mortality, with benefits seen in up to 7+ portions daily. Further investigations into the effects of different types of fruit and vegetables are warranted.
Non-specific abdominal pain (NSAP) is the most common diagnosis on discharge following admission for abdominal pain in childhood. Our aim was to determine the risk of subsequent hospital diagnosis of organic and functional gastroenterological conditions following a diagnosis of NSAP, and to assess the persistence of this risk. An NSAP cohort of 268 623 children aged 0-16 years was constructed from linked English Hospital Episode Statistics from 1999 to 2011. The control cohort (1 684 923 children, 0-16 years old) comprised children hospitalised with unrelated conditions. Clinically relevant outcomes were selected and standardised rate ratios were calculated. From the NSAP cohort, 15 515 (5.8%) were later hospitalised with bowel pathology and 13 301 (5%) with a specific functional disorder. Notably, there was a 4.84 (95% CI 4.45 to 5.27) times greater risk of Crohn's disease following NSAP and a 4.23 (4.13 to 4.33) greater risk of acute appendicitis than in the control cohort. The risk of irritable bowel syndrome (IBS) was 7.22 (6.65 to 7.85) times greater following NSAP. The risks of inflammatory bowel disease (IBD), IBS and functional disorder (unspecified) were significantly increased in all age groups except <2-year-olds. The risk of underlying bowel pathology remained raised up to 10 years after first diagnosis with NSAP. Only a small proportion of those with NSAP go on to be hospitalised with underlying bowel pathology. However, their risk is increased even at 10 years after the first hospital admission with NSAP. Diagnostic strategies need to be assessed and refined and active surveillance employed for children with NSAP. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to
Functional abdominal pain (FAP) is associated with significant anxiety and impairment. Prior investigations of child anxiety in youth with FAP are generally limited by small sample sizes, based on child report, and use lengthy diagnostic tools. It is unknown whether a brief anxiety-screening tool is feasible, whether parent and child reports of anxiety are congruent, and whether parent and child agreement of child anxiety corresponds to increased impairment. The purpose of this investigation was to examine anxiety characteristics in youth with FAP using parent and child reports. Parent-child agreement of child anxiety symptoms was examined in relation to pain and disability. One hundred patients with FAP (8-18 years of age) recruited from pediatric gastroenterology clinics completed measures of pain intensity (Numeric Rating Scale) and disability (Functional Disability Inventory). Patients and caregivers both completed a measure of child anxiety characteristics (Screen for Child Anxiety and Related Disorders). Clinically significant anxiety symptoms were more commonly reported by youth (54%) than their parents (30%). Panic/somatic symptoms, generalized anxiety, and separation anxiety were most commonly endorsed by patients, whereas generalized anxiety, separation anxiety, and school avoidance were most commonly reported by parents. The majority (65%) of parents and children agreed on the presence (26%) or absence (39%) of clinically significant anxiety. Parent-child agreement of clinically significant anxiety was related to increased impairment. A brief screening instrument of parent and child reports of anxiety can provide clinically relevant information for comprehensive treatment planning in children with FAP.
#### The bottom line Irritable bowel syndrome (IBS) is a chronic gastrointestinal disorder with an estimated prevalence of 10-20%.1 The condition mostly affects people aged 20-30 years and is twice as common in women as in men.1 It can be painful and debilitating, lead to feelings of anxiety and depression, and negatively affect quality of life.1 This article summarises the most recent recommendations from the National Institute for Health and Care Excellence (NICE) on irritable bowel syndrome in adults in primary care.2 NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. Where the evidence was minimal, recommendations in the original guidance were based on the guideline development group’s experience and opinion of what constitutes good practice. Changes in this update are based on evidence from updated systematic reviews and updated evidence on cost effectiveness. Evidence levels for the recommendations are given in italic in square brackets. ### Initial assessment
Objectives: The diagnostic accuracy of faecal calprotectin (FC) concentration for paediatric inflammatory bowel disease (IBD) is well described at the population level, but not at the individual level. We reassessed the diagnostic accuracy of FC in children with suspected IBD and developed an individual risk prediction rule using individual patient data. Methods: MEDLINE, EMBASE, DARE, and MEDION databases were searched to identify cohort studies evaluating the diagnostic performance of FC in paediatric patients suspected of having IBD. A standard study-level meta-analysis was performed. In an individual patient data meta-analysis, we reanalysed the diagnostic accuracy on a merged patient dataset. Using logistic regression analysis we investigated whether and how the FC value and patient characteristics influence the diagnostic precision. A prediction rule was derived for use in clinical practice and implemented in a spreadsheet calculator. Results: According to the study-level meta-analysis (9 studies, describing 853 patients), FC has a high overall sensitivity of 0.97 (95% confidence interval [CI] 0.92-0.99) and a specificity of 0.70 (0.59-0.79) for diagnosing IBD. In the patient-level pooled analysis of 742 patients from 8 diagnostic accuracy studies, we calculated that at an FC cutoff level of 50 μg/g there would be 17% (95% CI 15-20) false-positive and 2% (1-3) false-negative results. The final logistic regression model was based on individual data of 545 patients and included both FC level and age. The area under the receiver operating characteristic curve of this derived prediction model was 0.92 (95% CI 0.89-0.94). Conclusions: In high-prevalence circumstances, FC can be used as a noninvasive biomarker of paediatric IBD with only a small risk of missing cases. To quantify the individual patients' risk, we developed a simple prediction model based on FC concentration and age. Although the derived prediction rule cannot substitute the clinical diagnostic process, it can help in selecting patients for endoscopic evaluation.
Objectives: Irritable bowel syndrome (IBS) is a chronic, disabling condition that greatly compromises patient functioning. The aim of this study was to assess the impact of a 6-week twice per week Iyengar yoga (IY) program on IBS symptoms in adolescents and young adults (YA) with IBS compared with a usual-care waitlist control group. Methods: Assessments of symptoms, global improvement, pain, health-related quality of life, psychological distress, functional disability, fatigue, and sleep were collected pre- and posttreatment. Weekly ratings of pain, IBS symptoms, and global improvement were also recorded until 2-month follow-up. A total of 51 participants completed the intervention (yoga = 29; usual-care waitlist = 22). Results: Baseline attrition was 24%. On average, the yoga group attended 75% of classes. Analyses were divided by age group. Relative to controls, adolescents (14-17 years) assigned to yoga reported significantly improved physical functioning, whereas YA (18-26 years) assigned to yoga reported significantly improved IBS symptoms, global improvement, disability, psychological distress, sleep quality, and fatigue. Although abdominal pain intensity was statistically unchanged, 44% of adolescents and 46% of YA reported a minimally clinically significant reduction in pain following yoga, and one-third of YA reported clinically significant levels of global symptom improvement. Analysis of the uncontrolled effects and maintenance of treatment effects for adolescents revealed global improvement immediately post-yoga that was not maintained at follow-up. For YA, global improvement, worst pain, constipation, and nausea were significantly improved postyoga, but only global improvement, worst pain, and nausea maintained at the 2-month follow-up. Conclusions: The findings suggest that a brief IY intervention is a feasible and safe adjunctive treatment for young people with IBS, leading to benefits in a number of IBS-specific and general functioning domains for YA. The age-specific results suggest that yoga interventions may be most fruitful when developmentally tailored.
Objectives: It has been suggested that different subcategories of childhood abdominal pain-related functional gastrointestinal disorders (AP-FGIDs) are not separate clinical entities, but represent variable expressions of the same FGID. The aim of the present study was to compare clinical and psychological characteristics of children with irritable bowel syndrome (IBS), functional abdominal pain (FAP), and functional abdominal pain syndrome (FAPS). Methods: A total of 259 children, ages 8 to 18 years, fulfilling Rome III criteria for IBS or FAPS were included in a randomized controlled trial evaluating the effect of hypnotherapy. At inclusion, questionnaires assessed demographics, clinical features, abdominal pain frequency and intensity, depression and anxiety, somatization, health-related quality of life, pain beliefs, and coping strategies. Results: No differences were found between children with IBS and those with FAPS with respect to the main outcomes: frequency and intensity of abdominal pain, symptoms of depression and anxiety, somatization, health-related quality of life, pain beliefs, and coping strategies. A significantly higher percentage of patients with IBS had a positive family history for AP-FGIDs (56.8% vs 37.8%; P = 0.00). Characteristics of patients with IBS subtypes did not differ. Patients with FAP or FAPS differed only with respect to problem-focused coping strategy (2.21 ± 0.61 vs 2.52 ± 0.49; P = 0.00). Conclusions: Pediatric patients with IBS and those with FAPS have similar psychosocial profiles. These results may explain why treatment response of psychological therapies in these AP-FGIDs is similar. These results may indicate that pediatric IBS and FAPS are different expressions of 1 underlying functional disorder, but similarities in psychosocial characteristics do not exclude the possibility that these disorders are different entities, because these similarities can exist between disorders of various causes. Therefore, future research is required on the role of other (physiological) factors in pediatric IBS and FAPS.
Recurrent pain symptoms in children are associated with psychiatric comorbidities that could complicate treatment. We investigated the prevalence of psychiatric comorbidity in children with recurrent headache or recurrent abdominal pain and evaluated the screening potential of the Strength and Difficulties Questionnaire compared with the Development and Well-Being Assessment (DAWBA). Eighty-three outpatients aged 5-17 years attending a tertiary medical center for a primary diagnosis of migraine (n = 32), tension-type headache (n = 32), or recurrent abdominal pain (n = 19), and 33 healthy matched controls completed the brief self-reporting Strength and Difficulties Questionnaire followed by the Development and Well-Being Assessment. Findings were compared among groups and between instruments. The pain groups were characterized by a significantly higher number of Development and Well-Being Assessment diagnoses (range 0-11) than controls and a significantly greater prevalence (by category) of Development and Well-Being Assessment diagnoses (P < 0.001 for both). Anxiety and depression were the most prevalent Development and Well-Being Assessment diagnoses. Comorbidities were more severe in the headache groups than the controls (P < 0.001). In general, any diagnosis by the Development and Well-Being Assessment was associated with a significantly higher Strength and Difficulties Questionnaire score (P < 0.001). Abnormal scores on the emotional, conduct, and hyperactivity Strength and Difficulties Questionnaire scales were significantly predictive of a Development and Well-Being Assessment diagnosis (P < 0.003). Children referred to specialized outpatient pediatric units for evaluation of recurrent pain are at high risk of psychopathology. The Strength and Difficulties Questionnaire may serve as a rapid cost-effective tool for initial screening of these patients.