Functional pain in childhood

ד"ר דקלה אגור, ד"ר מוניקה קראוס, ד"ר אירנה שטיינפלדהמחלקה לרפואת משפחה חיפה

Girl age 8

כאבי בטן חוזרים מאז ספטמבר. 8ליהי בת ,כאבים הגורמים להחמיץ ימי לימודים. לאחרונה

החמרה בעוצמת הכאב.

שני ההורים עובדים, עד עכשיו קבלו את כאביהבטן כ"תופעה חולפת" אך עתה מבקשים

Reassurance.

RAS- What is it?

Recurrent abdominal pain

Apley and Naish 1958: ‘abdo pain that waxes and wanes, occurs for at least 3 episodes within 3 months and is severe enough to affect a child’s activities

Other names

Rome 111 criteria: functional dyspepsia

Irritable bowel syndromeFunctional abdominal painAbdominal migraine

Prevalence :

Community based studies vary from 0.5 – 19%

Age peaks: 4- 6 years and 7 – 12

Are girls more likely to be affected?

Is it all helicobacter?

Lin et al: 2006, Hepatogastroenterology 53 (72) 883-6 (Taiwan)

135 patients with FAPAll endoscoped, urease breath tests:

43.7% normal 19.3% Esophagitis 13.3 peptic ulcer, 7.4% gastritis. 23.7% had evidence of helicobacter

infection

At follow up:

No difference in pain in long term follow up of those with and those without helicobacter disease

77% of children continued with same degree of pain

Causes:

Multifactorial, not understood. Visceral sensation, alterations in gastrointestinal motility, psychological factors

Those with bacterial colitis more likely to develop irritable bowel if infection occurs during stressful life events

Making the diagnosis confidently

History and examinationTalk to the childExacerbating factors?Relieving factors?Acknowledge distress

Making the diagnosis confidently

No diagnostic tools BUT absence of ‘alarm factors’(American Academy :

Paediatrics 2005)

Involuntary weight lossPoor linear growthGI blood lossSignificant vomitingChronic severe diarrhoeaUnexplained feverFH of inflammatory bowel disease

Which comes first? Anxiety or pain?

No studies could show that stressful life events significantly differentiate patients with organic and ‘non organic pain’

Headache, anorexia, nausea, constipation or arthralgia occur as often in children with ‘functional organic pain’ as those with ‘organic’ pain

Diagnosis: factors likely to be related

Alarm symptoms increase risk of organic disease

Age of child; parental anxiety in first year of life, parents with GI problems, low SE status

Poor prognosis: if parents ( or paediatrician) cannot accept functional disorder, parental attention to childs problems, stressful events, parental functional problems, sexual abuse

Inconclusive associations:

Helicobacter positivity and positive endomysial ab (celiac)

Female sex, anxiety, depression, stressful life event

Prognosis: age, female sex, self confidence, parental coping style

Unlikely to be related :

Pain characteristics, frequency, severityDepressionLactose malabsorbtion

Prognosis

Most relatively mild. In a Dutch survey only 2% required referral

Some studies suggest that may be an increased incidence in adult irritable bowel syndrome in this group

Family history of irritable bowel:

Pace et al: World J Gastroenterol: 2006, 12(240) 3874-7

Cohort of 67 children with RAP followed for 5 – 13 years

15/52 (29%) has IBS. this group higher prevalence of back pain, myalgia, sleep disturbance and FH of irritable bowel

Management

Validate the child’s experienceExplore the family’s understanding and

beliefs of abdominal painMay need to do some tests to reassure child

and family – but resist over investigationExplain the link between emotions and

visceral symptoms – ‘holistic view’

Using a diary

Ask CHILD to keep a pain diary ‘being a detective’ Score 0-5Review diary with child

Evaluating treatments:

Cognitive behaviour therapy – 3 randomized trials showed benefit

Peppermint oil – may helpRole of pizotifen (Sanomigran®) ??

More research needed!

Our patient:

High academic achieverConscientious and anxious to do wellScary teacherPain worse on needlework lesson days…..

When to investigate

If ‘alarm’ symptomsIf pain not typical – e.g. in the renal area. US

may show obstructionIf there are family health beliefs

And its all food allergy, doc.…

Make sure the diet is ‘safe’Explain the limitation of allergy testingDiscuss celiac diseaseEncourage ‘food challenges’ to reintroduce

food into the diet

ש' מתלוננת בחודשים האחרונים על כאב ראש 12נועה בת מצחי יום יומי. אינה מקיאה, אין לה חום או תלונות נוספות.

מדי פעם לוקחת אקמול או נורופן להקלת הכאב.

מעברה - בריאה בד"כ

תלמידה טובה, חברותית, הולכת לצופים.

לציין- האם סובלת ממיגרנה.

בדיקה גופנית כולל בדיקה נוירולוגית גסה - תקינה. ל.ד. 120/70

בדיקת עיניים תקינה.

מעבדה ??

ס.ד., כימיה תקינה.

Epidemiology of Headache

Most common cause of childhood painUncommon beforeUncommon before 4 years4 yearsPrevalence of all types increases with agePrevalence of all types increases with age< 10-12 years< 10-12 years equal among sexes,

male:female 1 : 1male:female 1 : 1 > >10-1210-12 yearsyears greater prevalence in girls girls (1 :

1.51.5)most are MIGRAINEMIGRAINE or TENSIONTENSIONremission occurs in 70%remission occurs in 70% of cases ages 9-16 ages 9-16

yearsyears1/3 remain headache free after 6 years ,

2/3 remain headache free after 16 years

Classification of Headache

PRIMARYPRIMARY = Benign (Migraine, Tension, Cluster)= Benign (Migraine, Tension, Cluster) exam normal no papilledema normal neuroimaging no fever / meningismus, normal CSF

SECONDARY = malignant, symptomaticSECONDARY = malignant, symptomatic Something’s wrongSomething’s wrong

Migraine

Genetic predispositionGenetic predisposition, esp. “classic”“classic” with aura ““Common”Common” without aura - 70-85 % children TriggersTriggers: sleep deprived, hunger, illness, travel,

stress (only 50 % migraineurs can identify trigger)

Frontotemporal pain Frontotemporal pain (anterior, uni- or bilateral) Autonomic symptomsAutonomic symptoms:

Nausea/vomiting or photo-/phonophobia, pallor May be preceded by transient auraaura (< 1 hr, 15-

30min) Visual aura most common

Association of migrainesmigraines in children with other conditions:

Somatic pain complaints Abdominal (diffuse non-localizing crampiness)

8-15 % epilepticepileptic children 21 % psychiatrically illpsychiatrically ill children

major depression panic attacks or other anxiety disorder

Migraine-related syndromes (variants)

Benign paroxysmal vertigoBenign paroxysmal vertigo recurrent stereotyped bouts of vertigo often with nausea, vomiting, nystagmus

Cyclic vomitingCyclic vomiting recurrent severe sudden nausea and

vomiting attacks last hours to days symptom-free between attacks

Pain typically posteriorposterior > anterior, or band-likeband-like SqueezingSqueezing quality (tight, vice-like) Neck muscles sore Common trigger: STRESS !STRESS ! NONO autonomic symptoms

NO nausea/vomiting or photo/phonophobia NONO aura Best treatments:

NSAIDs, relaxation / biofeedback

Tension headache

5+ 5+ per week week15+ 15+ per month monthNo underlying pathologyNo underlying pathologyMigraines Migraines that have changed character:changed character:

Poor pain controlPoor pain control Psychosocial causesPsychosocial causes Medication overuse Medication overuse (“rebound

headaches”)

“Chronic Daily Headaches”

Avoid / minimizeminimize triggers (MIGRAINES)triggers (MIGRAINES) Optimize hydration Good sleep hygiene / avoid sleep

deprivation Avoid hunger Avoid food triggers (aged cheeses,

chocolate, caffeine/ soda, processed deli meats, MSG, red wine)

Mind-Body approach - minimize stressminimize stress Biofeedback / relaxation , Self-hypnosis Acupuncture

Treatment for primary recurrent headache

headache is always in the same locationsame location focal neurologic findingsfocal neurologic findings appear (in first 2-6

m) VI n. palsy, diplopia, new onset strabismus,

papilledema Hemiparesis, ataxia

progressively increasingprogressively increasing frequency / severity of headache, headache worse with valsalva

headache awakens from sleep, worse in the awakens from sleep, worse in the morning, AM vomitingmorning, AM vomiting

at-risk hx or condition: at-risk hx or condition: VPS, neurocutaneous disorder

Rethink the diagnosis of benign headache:

BEING POSITIVE!

Functional pain in childhood