functional pain in childhood ד"ר דקלה אגור, ד"ר מוניקה קראוס,...
TRANSCRIPT
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