When is a child considered to have recurrent abdominal pain (RAP) in childhood??

Introduction

Stomachache or abdominal pain is a common complaint among children. Abdominal pain by itself is not a disease but is a symptom of a variety of underlying disorders. If your child has repeated abdominal pains, he or she may be suffering from recurrent abdominal pain.

What is Recurrent Abdominal Pain (RAP)?

• Presence of three or more episodes of pain over a period of 3 months
• Occurs at least once a month
• Painful enough to effect child’s daily avtivities
• Typically affecting those aged 4 – 16 years

How serious is the problem of RAP?

It is a benign condition but this condition has been associated with increased school absenteeism, frequent hospital or clinic visits, family disruption and significant anxiety.
Incidence

• Affects 10% – 15% of children
• 1st peak at ages 5 – 7 years with boys and girls equally affected
• 2nd peak at age 8 – 12 years with girls being more frequently affected
• 80% – 90% is caused by functional or psychogenic causes

Why does a child have RAP?

Various causes have been postulated. They are generally classified as :

Psychogenic causes

The abdominal pain occurs in non-diseased organs. Pain is believed to arise from stress, anxiety and depression. Situational stresses on a susceptible child are thought to be the cause of the pain. The real mechanism by which this process happens is not known.

Functional cause

In this type, the affected organs are not diseased but there is an abnormal or changed functioning as a result of certain interactions between the body and the environment. Examples include :

• Lactose intolerance
• Dysmenorrhoea
• Constipation

Organic causes

This type of abdominal pain is secondary to an underlying disease in the child’s body. Examples include :

• Inflammatory bowel disease
• Peptic ulcer disease – up to 50% is related to Helicobacter pylori disease
• Worm infestation
• Pelvic inflammatory disease
• Ovarian cyst

What are the features of RAP and how is the diagnosis made?

It is important to examine each child carefully and types of RAP may show as follows :

Psychogenic type

• Pain may occur once daily or less frequently (i.e. weekly or even monthly)
• Pain usually lasts less than 1 hour
• It is vague, ill-defined; sometimes can be crampy/colicky or bloating
• It is located usually around periumbilical (navel) area
• Symptoms do not progress
• Symptoms are unrelated to meals, activity or stool pattern
• Caution : Any change in location or pattern of pain may indicate an actual underlying illness

Functional type

• Pain often associated with diet, eating or bowel habits
• Cramping or bloating sensation frequently present
• Location of pain depends on underlying cause

Organic type

• Characteristics of pain are dependant on underlying disease
• The presence of fever, loss of weight, heartburn, diarrhoea etc should alert parents to the possibility of organic causes

Other commonly associated symptoms symptoms include:

Headache, dizziness, increased sweating, pale face are more commonly associated with psychogenic causes.

The following symptoms are more commonly associated with organic or functional causes :

• Fatigue
• Anorexia
• Nausea with or without vomiting
• Diarrhea
• Constipation
• Limb pain

Diagnosis

• Diagnosis is often difficult and you should consult your doctor about this problem.
• If your child has recurrent abdominal pain, ideally you should bring your child to your doctor when he/she is having the pain.
• However more often, children are brought to see their doctors when they are completely free of pain making evaluation difficult.
• RAP is usually caused by psychogenic or functional causes. Careful history taking and examination by your doctors is usually adequate to dismiss organic causes of the abdominal pain.
• Multiple tests and invasive procedures are not recommended and may cause more distress to your child.

Is there further harm in RAP in childhood?

There can certainly be undesirable consequences.

Complications of psychogenic RAP

1. Affects psychosocial function
   • Results in absenteeism from school; affects learning
   • Affects peer relationships
   • Prevents the child’s participation in school or family activities
2. Reinforces pain consequence behaviour
   • Increases dependence on parents; inability to explore own independence
     • Getting used to being sent home from school
     • Expecting to stay home all the time
     • Expecting parents to always fuss over him/her
   • Taking multiple medications

In Psychogenic RAP, pain usually last about an hour, the child is completely well after that. Therefore sending the child home from school or keeping him home away from school should not be the way to handle his problem.

Complications of organic and functional types of RAP

This depends on the underlying disease.

How is RAP treated?

Treatment would depend on the underlying cause. In organic or functional RAP, doctors might employ various measures including dietary intervention or medications.

For Psychogenic RAP

Generally doctors would rightly reassure parents and patiens that there is no serious disease present and provide support to the family. Children will eventually outgrow the condition but in the meantime, must learn and be given support to cope with it.

• Goal of treatment in Psychogenic RAP :
  • A return to normal function and relief of symptoms

• Strategies of treatment in Psychogenic RAP :
  • Promoting child’s independence / self reliance
  • Discouraging negative consequence behaviour
  • Not keeping child away from school unnecessarily
  • Not withdrawing child from school/family activities
  • Stop treating child as sick and stop pampering child
  • Identifying stressors in child’s life; then either eliminating the stress or helping the child cope with the stress

• Things to do when your child is in pain
  • Distraction techniques – distract your child with other interesting activities or toys
  • Relaxation techniques – eg. simple breathing exercises

Medications or drugs are generally not useful. Consult your doctor for help in managing your child.

Treatment of Functional RAP

Identifying and treating the underlying disorder

• Education
• Change diet habits – e.g. trial of lactose free diet in lactose intolerance, trial of high fibre diet in constipated children. Avoidance of high fat foods and caffeinated beverages that may aggravate dyspepsia.
• Regulate bowel habits
• Simple analgesia – i.e. Paracetamol for dysmenorrhoea

Treatment of Organic RAP

This depends on the underlying disease

Are there any measures that can be taken to prevent psychogenic RAP?

You should identify the various factors that can contribute to your child’s behaviour and seek professional help where necessary.

• Your child may be the only child or youngest in the family
• You may be overly protective or over anxious of your child’s welfare all the time
• You are too preoccupied with child’s activities
• Your family may have other members who suffer from chronic pain (from other causes)
• Your child frequently demonstrates immature behaviour; overly dependent on you, throwing tantrums etc

Outcome

For the Psychogenic type of RAP, 30 to 40% of children will eventually outgrow it with resolution of pain. Others may still have some residual problems with their condition.

Last reviewed	:	26 September 2008
Content Writer	:	Dr. Lim Sern Chin
		Dato’ Dr. Lim Nyok Ling