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Practical management of functional abdominal pain
in children
L K Brown,
1
R M Beattie,
2
M P Tighe
1
1
Department of Paediatric,
Poole Hospital NHS Trust,
Poole, Dorset, UK
2
Department of Child Health,
University Hospital
Southampton, Southampton,
UK
Correspondence to
Dr M P Tighe, Department of
Paediatrics, Poole Hospital NHS
Trust, Longfleet Rd, Poole
BH15 2JB, Dorset, UK;
mpt195@hotmail.com
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/
archdischild-2014-306426
ABSTRACT
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.
CASE STUDY
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.
WHAT IS FUNCTIONAL ABDOMINAL PAIN?
‘….at least 3 bouts of pain, severe enough to affect
activities, over a period of not less than three
months.’
1
Recurrent abdominal pain (RAP) is a common
presentation to general practitioners and paediatric
outpatient clinics. A prevalence of 10–30% has
been reported, with some studies showing a higher
rate in females. Peaks in age occur from 4–6 years
of age, and 9–11 years; however, children outside
these age groups often present with symptoms.
1–3
Currently, paediatric functional gastrointestinal
(GI) disorders are categorised within the Rome
Criteria III (table 1).
4
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.
5
‘IS IT ALL IN HER HEAD?’
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 child’s 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 brain–gut axis.
Giving the family an understanding of how pain
can be generated without noxious stimuli is key to
managing RAP. Figure 1 is a simplified schema that
may help patients’and parents’understanding.
Central and visceral hypersensitivity are key con-
cepts and underpin the perception of the ‘true’pain
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.
6
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.
7
Such mechanisms may explain what is thought to
be a lowering of the individual’s 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
implemented.
8
Communication of the biopsychosocial theory of
pain is valuable in the child’s 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.
9
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 modifiable, lays
solid foundations for long-term recovery.
‘WHYMYDAUGHTER?’
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;0:1–7. doi:10.1136/archdischild-2014-306426 1
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95% CI 1.3 to 3.9).
10
Another study found that adults with IBS
were three times more likely to have siblings with a functional
gut disorder.
11
Twin studies also identified a genetic predisposition to RAP
syndromes. The genetic concordance of 8.4% was seen between
dizygotic twins versus 17.2% in monozygotic twins.
12
However,
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 reflux 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 significance did not persist
after logistic regression was performed to remove potential con-
founding variables of anxiety and depression.
13
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 significant 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
3
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
child’s 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 subject’s 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 Intolerance—poor diet, wheat, carbohydrate intolerance, excess sorbitol Separation of a family member—divorce, 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;0:1–7. doi:10.1136/archdischild-2014-306426
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abuse, in any form, should always be considered when children
report illness that poses a diagnostic challenge.
14
Personality
Early studies noted that ‘emotional children’were more prone to
developing FAP.
1
More recently, it has been shown that children
with FAP internalise problems and are more likely to have emo-
tional disorders
15
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.
16
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).
17
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 ‘accommodate’stress,
to accept difficulties, encourage themselves to keep going and
readjust with a positive outlook. This may promote negative
affect and worsen abdominal pain.
19
The family and parental influence on pain
The home and family dynamic influence functional symptoms
in multiple ways. The effect of living among a family in conflict
is related to higher functional disability in children with RAP. In
78 children with functional symptoms, the child’s symptom
scores were compared with the family environment scale, and
aspects such as family conflict and family organisation were sig-
nificantly correlated on multiple regression analysis (family con-
flict, β=0.43, r
2
change=0.18, p<0.001, and lack of family
organisation, β=–0.30, r
2
change=0.09, p<0.01) perhaps as
the child’s pain may be diversionary.
9
Particular roles can
emerge, the child adopting a ‘sick role’and a parent the ‘care-
giver’,
16
the caregiver may extend their role; reinforcing symp-
toms, rather than encouraging rehabilitation.
20
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).
2
Mothers of children with FAP
have a higher incidence of depression, anxiety and somatic
scores compared with mothers of children without FAP.
3
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).
21
Also, children of mothers with higher educa-
tional attainment were at greater risk of developing FAP.
3
School
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-specific abdominal pain
were seen within term time compared with holidays (rate ratio
1.42: 95%CI 1.25 to 1.61).
22
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 unidentified 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 flag symptoms
should alert the clinician to the possibility of inflammatory bowel
disease (IBD), coeliac disease or other organic causes of abdom-
inal pain (table 3). A characteristic history, in the absence of con-
cerning findings, suggests a functional GI condition (table 1).
4
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 significance of the condition
for the child, or reveal a trigger, including worries about the
pain.
23
Although primarily a GI disorder, children with FAP syn-
drome frequently report non-GI symptoms, for example, head-
ache, limb pains and dizziness.
2324
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 identified through history and
examination should guide initial investigations.
Figure 1 A biopsychosocial model of
pain: for use with parents and
patients.
Brown LK, et al.Arch Dis Child 2015;0:1–7. doi:10.1136/archdischild-2014-306426 3
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In the absence of ‘red flags’, 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; specificity
0.70; 95% 0.59 to 0.79) for diagnosing IBD, with only 2%
false negative result.
25
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).
26
Leucocyte count
was similar in the functional and pain-free group (mean values:
functional group 7.4×10
9
/L, vs pain-free group 8.3×10
9
/L,
p>0.05: not significant). Prevalence of stool parasites was 6/87
(7%) in the functional group and 9/70 (13%) in healthy con-
trols (p=0.28: not significant).
Parents may request a ‘scan’; however, there is no evidence to
suggest that ultrasound of abdomen/pelvis, in the absence of red
flag symptoms, has a significant yield of organic disease unless
there are specific 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 specific pointers in the history and
examination. Performing more tests on children with functional
symptoms that does not improve the identification of organic
disease invites further anxiety.
27
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 alarm’can 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 ‘oversensitive’and ‘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).
Reassurance
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 family’s
approach has the greatest impact on the course of the
disorder.
Distraction
Techniques to alleviate abdominal pain were compared in one
useful study.
28
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
MRI*
CT*
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;0:1–7. doi:10.1136/archdischild-2014-306426
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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 brain–gut 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 beneficial effects for non-headache pain, including
abdominal pain (7 studies).
29
These methods had some effect in
reducing pain (five studies: 357 participants: standard mean
difference (SMD) −0.51 (−0.8 to −0.22)), which was statistic-
ally significant, 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 significant (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 (14–17 years) showed 44% of adolescents reported signifi-
cantly reduced pain; this, however, was not sustained at
2-month follow-up.
30
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 efficacy.
MEDICATION
‘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
H
2
antagonists for Functional dyspepsia 1 RCT (n=25) showed subjective improvements but no objective reduction in pain
scores
42
Uncertain None significant
Lactose-free diet for RAP Cochrane review of 2 RCTs comparing lactose-containing and lactose-free diets (38
children).
34
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.
37
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%,
p=0.005).
Beneficial None
Probiotics for IBS or functional pain Cochrane meta-analysis of Lactobacillus:
27
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.
39
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:
38
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
benefit
None
Added fibre for IBS Cochrane review of 2 RCTs in 92 patients:
27
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.
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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 significant relief or cure
(table 6). In targeting the psychological elements of FAP, psycho-
tropic medications have been investigated; however, there is no
evidence of efficacy and clinicians should be wary of potential
side effects.
31
Diet
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 significant benefitfrom
lactose-free diets or supplemental fibre and a lack of quality evi-
dence.
32
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.
33
It
may be offered to patients as a 1-month trial for IBS.
Avoiding the classical 4 ‘C’trigger 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.
34
A recent study showed that eating seven pieces of fresh fruit
and vegetable benefits general health.
35
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.
36
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%).
36
For children with IBS a diet low in fibre, increasing the
fibre 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.
37
‘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
30.2).
38
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.
39
However, a higher proportion of chil-
dren may subsequently develop disease: a recent study of
>268 000 children admitted with non-specific abdominal pain
had a 4× relative risk of subsequent diagnosis of Crohn’s
disease and 3× risk of coeliac disease up to 10 years later
compared with a control group of children admitted with unre-
lated conditions.
40
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.
41
Known factors influencing persistence of symptoms:
▸patients who struggle to effectively employ coping
strategies;
42
▸hospitalisation due to pain or reports of very high pain
scores;
27
▸non-GI symptoms;
26
▸obese children (p<0.0017, over 12–15 months follow-up).
43
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).
44
This highlights the importance of
managing these families’expectations and may also indicate
raised family stress levels.
45
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.
CONCLUSION
Managing FAP requires skilled history-taking and examination,
coupled with communication skills that allow the clinician to
gain an understanding of the child’s pain, how multiple factors
influence 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 clinician’s ability to
adequately explain and engage the family. Clinicians should
reassess if new red flag symptoms occur and reinvestigate if
necessary.
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.
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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
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