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(Received June 9, 1969; revision accepted for publication January 2, 1970.)

This work is supported by the National Institute of Arthritis and Metabolic Diseases, U.S. Public

Health Service, Training Grant No. TI AM 05439.

ADDRESS: (G.J.B.) 230 North Broad Street, Philadelphia, Pennsylvania 19102.

PEDIATRICS. \‘ol. 45, No. 5, May 1970

ARTICLES

RECURRENT

ABDOMINAL

PAIN

IN

CHILDHOOD

Robert T. Stone, M.D., and Giulio J. Barbero, M.D.

Children’s Hospital of Philadelphia and Department of Pediatrics, Hahnemann Medical College and Hospital, Philadelphia, Pennsylcania

ABSTRACT. One hundred and two children with recurrent abdominal pain were studied and fol-lowed through hospitalization. The pain in this group was variable, with no consistent pattern in time, duration, and intensity. It was located in the periurnbilical region in 50 of the patients. Asso-ciated symptoms frequently included headache, pallor, nausea, vomiting, constipation, dizziness, and poor appetite. The principal physical finding was tenderness on deep palpation over various sec-tions of the abdomen. Proctoscopic findings in 88 of 90 patients examined were rectal dilatation, hy-peremic areas, pallor, lymphoid hyperplasia, pellet stools, edema, and friability. There were no other

abnormal laboratory or x-ray findings. Various be-havioral manifestations were observed in this group of children. Some of the children were able to delineate points of stress as precipitants of epi-sodes of pain.

During hospitalization there was total abatement of intestinal symptoms in 53% of the children and there was a decline in svmptomatology in another 38%.

It is proposed that the abdominal manifestations of this group of patients can be described as the irritable bowel syndrome in childhood. Pediatrics,

45:732, 1970, IRRITABLE BOWEL SYNDROME,

RECUR-RENT ABDOMINAL PAIN.

R

ECURRENT abdominal pain is a frequent problem in childhood.”2 While this complaint often represents a difficult diag-nostic problem, a number of reports have documented that the recurrent abdominal pain of childhood less commonly results from entities of clearly definable nature.1-4 Among adults, chronic and recurrent ab-dominal discomfort is a common disorder and is widely described as a common mani-festation of functional gastrointestinal ill-ness or “the irritable bowel syndrome.”’6 This report summarizes the clinical features of a selected group of children hospitalized with abdominal pain, a group which can be considered as having “the irritable bowel syndrome” of childhood.

SUBJECTS

One hundred and two children with a

history of recurrent abdominal pain,

re-ferred to one of the authors by community physicians after intensive outpatient man-agement and occasional hospitalizations, made up the study population. There were 62 male and 40 female children, with an age range of from 2% to 14 years; 92 of the

children were between 5-14 years. All the patients were cared for by one of the au-thors, and data ‘ere collected

systemati-cally on prepared forms used at initial out-patient assessment, subsequent intensive

evaluation in hospital, and frequent follow-up visits. The behavior of the children was observed by the physician, nurses, and par-ents during a period of approximately 2 weeks in the hospital. A free diet was used at this time. Interviews were undertaken in all instances with the mother, father, and child separately to explore features of the past and present parental and family ex-periences which might have bearing on the psychosomatic aspects of the abdominal pain.

CLINICAL

FINDINGS

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ARTICLES

pain varied widely from extreme levels of acute abdominal “colic” to minimal levels of

soreness. The degree and type of pain did not clearly distinguish these patients from various specific organic entities. The dura-tion of the pain was 5 to 60 minutes in 37% of the patients, 1 to 3 hours in 36%, and more than 3 hours in 27%. Prior to

admis-sion, 14% had pain less than 1 month, 31% had pain 1 to 6 months, 19 had pain 6

months to 2 years, and 16% had more than

2 years of recurrent pain. In 20 patients the duration was uncertain. The longest period of pain was 9 years. Generally, the pain could not be related to eating, bowel move-ments, or general activity, and it was aggra-vated by feeding and increased activity

only occasionally. A small number of pa-tients were awakened by the pain at night or were unable to sleep as a result of the pain. Location of the pain was

periumbili-cal in 50 patients, epigastric in 20,

infra-umbilical in 8, right

upper

quadrant in 1,

left upper quadrant in 1, right lower

quad-rant in 7, and left lower quadrant in 5. The

pain was too vague to localize in 10 pa-tients. The abdominal pain was characteris-tically erratic and variable, without any

consistent pattern in time, duration, and in-tensity. In fact, a well defined or predict-able course warrants continual scrutiny for a specific etiology, although even this pic-ture on investigation ultimately may not demonstrate a traditional organic entity.

Parents related the onset of pain to some significant event in 67% of the patients.

These included stresses of varying types, such as excitement, punishment, or familial disturbance. The pain followed a febrile ill-ness in some children, and in 23% it seemed to arise during or after some school activity.

Prior to initial contact, various diets and

medications (such as antispasmodics, ant-acids, sedatives, and tranquillizers) had

been used with little response.

Associated Symptoms

In these 102 patients there were addi-tional symptoms such as headache, pallor,

nausea, vomiting, obstipation, diminished

frequency of stools, dizziness, poor appe-tite, transient weight loss, low-grade fever,

pellet stools, and diarrhea, with an inci-dence as tabulated in Table I. These symp-toms were present during or between

epi-sodes of abdominal pain. Often the history of these symptoms had to be elicited, par-ticularly if they had been mild and

markedly overshadowed by an intense de-gree of abdominal pain. In certain

in-stances, the intensity of extra abdominal symptoms such as headache or dizziness was so great that the symptoms not only

ex-ceeded the recurrent abdominal pain hut also provoked fears of an intracranial le-sion.

PRIOR DIAGNOSES

The following diagnoses had been

con-sidered by the referring physicians or par-ents: appendicitis, 17%; duodenal ulcer, 14%; emotional disorders, 13%; an addi-tional 29% were referred with various diag-noses including carcinoma, cystic fibrosis, rheumatic fever, ileitis, and gastrointestinal

allergy. Diagnosis was not identified in the remaining 27%.

Gestation

PAST MEDICAL HISTORY

Forty-one percent of the pregnancies were accompanied by increased physiologic

symptoms. These were nausea and vomiting of more than 5 months’ duration, excessive tiredness necessitating protracted bedrest, or even hysterical paralysis. Twenty per-cent of the mothers had significant medical illness of more than 1 week’s duration during the pregnancy. Thirty-one percent had a complicated labor or delivery, and 12% required a cesarean section.

Neonatal History

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TABLE I

IN(’II)ENCE OF ASSOCIATED Syii’rots AND SJGNS

IN

10

(‘%sEs OF IIE(’UHRENT ABDOMINAL PAIN

S’ymptoin

Ileada(’lIe Pallor Vomiting Constipat ion 1)izziness Anorexia

Pain accentuated by food Intermittent (liarrilea Unexplained fever Weight loss

Extensive school absence Limb

Rectal bleeding Mouth ulcers

Incidence

.50

41

34

31

25

411

18

16

14

13

ii

(-)

multiple formula modifications with no striking symptomatic change.

Previous Illness

Thirty-one percent of these patients had prior admissions to other hospitals for eval-uation of abdominal complaints. Nine pa-tients had appendectomies, of which six were known to he histologically normal. Ten percent had past respiratory manifesta-tions diagnosed as allergy, and 27% had prior tonsillectomy and adenoidectomy.

Nineteen percent had sleep problems char-acterized by nightmares or restlessness re-sulting in the child’s sleeping with the

par-ents. Enuresis was present in 13% of the children.

FAMILY HISTORY

Family Constellation

The children were predominately at the beginning or end of the sibship: 40% were

oldest, 30% were youngest, 10% were only children, and 20% were middle children.

Parental Illness

Sixty-three (56% mothers and 44% fa-thers) of the parents had medical illnesses.

One half of the mothers described gas-trointestinal problems diagnosed as

func-tional by their physician and 10% had mi-graine headaches. Forty-six percent of the

fathers had gastrointestinal illness and 10% had migraine headaches.

Twenty-five percent of all parents had lost a parent by death or divorce before they were 20 years of age; 33% of such losses occurred before the child was 10

years of age.

PHYSICAL FINDINGS

On physical examination, all the children described tenderness on deep palpation without guarding over various sections of the abdomen. This was predominately in the lower abdomen, particularly as the sig-moid colon rolled under the palpating fin-gers in the left lower quadrant or over the ileocecal region in the right lower quad-rant. The location of this tenderness did not always correlate with the location of the

pain. At times the stool in the sigrnoid colon took the form of a chain of small segmented balls. Growth was generally adequate in these children: 13% were above the 97th percentile for height, 6% were below the 3rd percentile for weight, and 5% were

below the 3rd percentile for height.

X-RAY AND LABORATORY STUDIES

X-ray examinations performed immedi-ately prior to referral and in the hospital

in-cluded upper gastrointestinal series, small bowel study, and barium enema on all pa-tients. These were all normal and revealed no evidence of ulcer disease, regional ileitis, or colon disease. Stool examinations for ova

and parasites were carried out on all pa-tients and were negative, with the

excep-tion of one patient who had giardia infesta-tion. Guaiac test for occult blood obtained on a meat-containing diet was positive in half of the cases. It was not possible to re-late this to the episodes of pain. Procto-scopic examination was carried out by the senior author in 90 of the patients without prior preparation by enemas, laxatives, or sedation. All proctoscopies were done in the

knee-chest position by use of a 15 cm

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TABLE 11

INCIDENCE OF F’INI)INGS ON PUO(’TOSCOPIC

EXAMINATION IN 90 CHILDREN WITH

REcUIIU ENT ABOOM INAL PAIN

Finding

Normal

Dilated rectal lumen Ilyperemic areas Pallor

Lymphoid hyperplasia Pellet stool Edema Friability

Incidence

86

70

14

35 ARTICLES

source. Two were interpreted as normal; 88 showed the nonspecific findings listed in Table II. Blood counts were normal in all

patients.

Urinalyses were normal, with the

excep-tion of one in which pyuria was found. Urine cultures in all patients were negative, with the exception of one patient with sig-nificant bacteruria. Intravenous urogram

was carried out in 40% of the children,

in-cluding the patient with urinary tract infec-tion. The only abnormalities discovered were a double left collecting system in one

child and a congenital absence of the right kidney in another case. Urinalysis, urine culture, and blood urea nitrogen were nor-mal in these two patients.

An electroencephalogram was obtained in 70% of the patients. Of these, 7% were described as epileptiform. Of the remain-der, findings such as 14 and 6 per second spikes were reported in 16%, and instances of excess fast and slow activity were men-tioned in 36%.

PERIOD OF HOSPITALIZATION

Children with Abdominal Pain

Hospitalization was used as a diagnostic tool for studies and observation. Since the majority of the children had active symp-toms of pain at the time of hospital admis-sion, it was interesting to note that total abatement of intestinal symptoms occurred during hospitalization in 53% of the

pa-tients and a decline in symptomatology

oc-curred in another 38%. The study group was active in the inpatient setting and functioned well in a supervised play pro-gram. A series of behavioral patterns was commonly seen. The patients showed ob-vious attempts to please adults and obtain approval. Frequently a calm, soft spoken, and courteous child became more outspo-ken and aggressive toward peers,

caretak-ers, and parents during the later days of hospitalization. They showed a striking

sen-sitivity and insecurity, with considerable anticipation of dangers and failures for themselves and their families.

Many of the children worried about their

parents with respect to potential illness or

mishaps which might occur to them. A

fre-quent wish by many of the children was the hope that the family always would be well and happy. They frequently antici-pated the worst stemming from some ex-perience such as an x-ray examination. They also talked about concern for world peace and suffering of all people. They were generally very sensitive to any distress

in other children on the ward and were particularly responsive to younger children, whom they often soothed or amused. On talking with the physician, they were often

able to delineate points of stress or particu-lar experiences as precipitants for episodes of pain. They also indicated their dilemma with the fact that physicians, parents, and

other caretakers seemed to imply that they did not have a real basis for the pain. Paral-lel with this was the children’s feeling that

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736

Family Picture

The families of such children exhibited no uniform set of patterns as observed within the framework of this clinical study.

A frequent observation was the intense closeness of the family and a feeling of fear and uncertainty of the child’s ability to handle the experience of hospitalization. A

common parental fear was that the abdomi-nal pain was a manifestation of cancer, leukemia, or some dangerous illness. Often

the observations suggested that the paren-tal closeness and sensitivity to the child and his stresses interfered with the ability of the

parents to strengthen the child to cope with a symptomatic ailment such as the abdomi-nal pain. This dilemma was perceived by the parents as arising from their previous experiences with the child. A common clini-cal impression regarding the parents and child was that there was a contagious, cir-cular anxiety which seemed to heighten the

pain and fear in the child as well as block parental perception of its features. In

ad-dition, some of the families could be characterized by a high personal sense of responsibility “in doing things right.” They frequently showed anger and low tolerance with situations which did not measure up to their expectations, or they were exquisitely sensitive to and considerate of the pain and suffering of others. Some of the family life histories were punctuated by many

ill-nesses, stresses, and deaths. Specific in-stances of illness and death in close rela-tives, as well as major strains in family

unity and security, seemed to have become interwoven in the worries expressed by the

children.

DISCUSSION

The findings in this survey of a group of children with recurrent abdominal pain are consistent with a clinical picture of the ir-ritable bowel syndrome as described in

adults.56 Davidson and Wasserman7 ap-plied the term to a group of young children

with chronic, nonspecific diarrhea. The re-lationship of this group of young children who had diarrhea with the children with

recurrent abdominal pain of this study, dif-fering mainly in age and predominant clini-cal manifestation, is not clear.

The underlying disorder in the children

in this study is unknown. There is certainly a question of dysfunction of bowel activity, a feature which may be the basis of the

for-mation of pellet stools. This was shown in a recent paper which reflected heightened re-sponses to cholinergic stimulation in a simi-larly affected patient group.9 Pupillography

in such patients was shown to exhibit some degree of physiologic abberation of the au-tonomic nervous system following stress.1#{176} The association of dizziness, headaches, and pallor may be further manifestations of

this involvement.

The emotional area would appear to be important in the clinical picture of recur-rent abdominal pain in childhood.lS The high incidence of early difficulty as

re-flected by abnormal pregnancy history, neo-natal difficulty, and infant “colic” may be relevant to the familial epidemiology in these children with abdominal pain. All these features may be additional clues to the diagnosis of recurrent abdominal pain,

and they may influence the level of fear and the anticipation of danger exhibited by the family to their child’s current illness and life experiences.

It is tempting to apply some categoriza-tion to the personality type of both children and family; however, considerable

varia-tions exist. The high incidence of familial gastrointestinal complaints raises questions of some genetic or acquired familial dis-turbance as factors in the evolution of this

syndrome. It also may be too easy to empha-size the psychosomatic features of this dis-ability, since these appear to be important and woven into the general picture. The so-matic background will continue to require

further delineation.

In the area of clinical management, it

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ARTICLES 737

term “emotional” by the physician in refer-ring to the abdominal pain may become a

roadblock to further help. Such a judgmen-tal generalization without exploration of the

specffic features of the subfle areas of be-havior and feeling with parent and child is of little value. An effective action of the physician is his acceptance of the complaint as real, removing the onus from the child of having “made up” the entire group of symptoms. At the same time, a close rela-tionship and elucidation of some of the

fea-tures of the “pain under the pain” may often go far in helping the child.

Hospitalization seemed useful in

diagno-sis and management in those instances

where frequent outpatient visits and

ther-apy had not been accompanied by improve-ment or clarification of the clinical picture. Here, the opportunity to observe the

pat-tern of the pain as well as the emotional state of the child frequently resulted in fur-ther clarity and increased security for the

parent. The children appeared capable of handling the hospitalization in spite of hav-ing developed abdominal pain to stressful

events in the past.

The diagnosis of this symptom complex in children can be based on the following points:

1. A varied and erratic history of recur-rent abdominal pain.

2. Additional symptoms of facial pallor, dizziness, headache, and pellet stools.

3. Evidence of precipitation of pain with stress.

4. Tenderness on deep palpation of the lower abdomen commonly located over parts of the colon.

5. Frequent improvement of pain with hospitalization.

6. Negative laboratory and x-ray

exami-nation.

7. Proctoscopic findings of mucosal pal-lor, prominant vascular markings, localized

areas of hyperemia, pellet stools, dilated rectal lumen, and lymphoid hyperplasia.

8. Evidence of past and present emo-tional upheaval or distress in child and

family.

This constellation may be one of the more common ailments of childhood, an

in-cidence of 10% having been documented by Apley1’2 in a group of school children.

The presence of a normal physical exam, except for tenderness over a part or all of

the colon, was striking. The normal

labora-tory and x-ray studies were characteristic of this group and have been noted in other studies.14, Proctoscopy may be a useful ad-junct to diagnosis and allow further insight into the physiology of the colon. The

im-portance of the observations from

procto-scopic examination require further control evaluation and histologic examination by rectal biopsy. The change in the abdominal

pain frequently seen with hospitalization under the care conditions of this study may also be a diagnostic clue. Although

informa-tion on various history factors and procto-scopic observations in a control population would obviously be valuable, such data have been difficult to secure and require further controlled examination.

Questions regarding food allergies or in-tolerances as being responsible for the

at-tacks of pain frequently had arisen in these

patients. Such implications lead to a multi-tude of dietary restrictions more related to the folklore of food and its impact than to

careful clinical observation. More impor-tant, the use of dietary approaches tends to

create an iatrogenically-induced viewpoint of disease in a body which may have all nat-ural proclivities to return to health

sponta-neously in many instances. The need to treat by manipulations may often stand in the way of a long-range point of view of unbiased clinical inquiry and the develop-ment of a supportive and reflective relation-ship between the patient, his family, and the physician to hasten the well-being of the patient.

The incidence of colonic carcinoma, pep-tic ulcer, granulomatous or ulcerative

(7)

headaches, or functional somatic symp-toms) would be of particular interest in this

disorder. These important epidemiological

questions need to be answered by long-term follow-up.

SUMMARY

The clinical picture of 102 children with

abdominal pain as their primary symptom has been described. In addition to abdomi-nal pain and tenderness over the colon,

symptoms such as headaches, pallor, and dizziness were present in these patients. Proctoscopic examinations performed in 90 patients showed nonspecific findings of some potential diagnostic importance. A clinical definition of this symptom complex as a form of the irritable bowel syndrome in childhood has been tabulated.

REFERENCES

1.Apley, J., and Nash, N.: Reccurent abdominal pain: A full survey of 1000 school children. Arch. Dis. Child., 33:165, 1958.

2. Apley, J.: The Child with Abdominal Pains.

Philadelphia: F. A. Davis Company, 1959;

2nd printing, 1964.

3. Conway, D. J.: A study of abdominal pain in

children. Great Ormand St.

J.,

29:99, 1951. 4. Wood, J.

L.,

Hardy, M.

L.,

and White,

H.:

Chronic Vague Abdominal Pain in Children. Pediat. Clin. N. Amer., 2:465, 1955. 5. Lumsden, K., Chaudhary, N., and Truelove,

S. C.: The irritable colon syndrome. Quart.

J.

Med., 31:123, 1962.

6. Kirshner, J. B., and Palmer, W. C.: The irrita-ble colon. Gastroenterology, 34:491, 1958. 7. Davidson, M., and Wasserman, R.: The

irrita-ble colon of childhood (chronic non-specific diarrhea syndrome).

J.

Pediat., 69:6, 1966. 8. Green, M.: Psychogenic, recurrent, abdominal

pain. PEDIATRICS, 40:84, 1967.

9. Kopel, F., Kim, I., and Barbero, G. J.: Com-parison of rectosigmoid motility in normal children, children with recurrent abdominal pain, and children with ulcerative colitis. PEDIATRICS, 39:4, 1967.

10.

Rubin, L. S., Barbero, C. J., and

M. S.: Pupillary reactivity in children with re-current abdominal pain. Psychosomatic

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1970;45;732

Pediatrics

Robert T. Stone and Giulio J. Barbero

RECURRENT ABDOMINAL PAIN IN CHILDHOOD

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1970;45;732

Pediatrics

Robert T. Stone and Giulio J. Barbero

RECURRENT ABDOMINAL PAIN IN CHILDHOOD

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