NR 602 Childhood Functional Abdominal Pain

NR 602 Childhood Functional Abdominal Pain

NR 602 Childhood Functional Abdominal Pain

Childhood Functional Abdominal Pain and Functional Abdominal Pain Syndrome

Children who have recurrent abdominal pain with no specific organic etiology are said to have functional abdominal pain (FAP), which is also known as recurrent abdominal painand is often a puzzling problem for providers. FAP is much more common than organic reasons for abdominal pain. The Rome III criteria are used as the diagnostic standards (Rasquin et?al, 2006; Rutten et?al, 2014). These criteria include:

• FAP: The following must occur at least once per week for at least 2 months before diagnosis:
• Episodic or continuous abdominal pain
• Insufficient criteria for other functional GI disorders
• No evidence of an inflammatory, anatomic, metabolic, or neoplastic process to explain symptoms
• Functional abdominal pain syndrome (FAPS): One or more of the following must occur at least once per week for at least 2 months before diagnosis and include childhood FAP criteria at least 25% of the time:
• Some loss of daily functioning
• Additional somatic symptoms, such as headache, limb pain, or difficulty sleeping

FAP is a fairly common pediatric complaint. The cause of the pain remains unclear, but the pain is genuine. There is no evidence of visceral hypersensitivity in the rectum (Rasquin et?al, 2006; Rutten et?al, 2014) as occurs with IBS. Affected children have an involuntary predisposition for the development of physiologic pain (e.g., a family history of FAP). Temperament and personality can make the child more vulnerable to environmental stressors (often minor) that precipitate the sensation of pain. Children who are perfectionists and have a tendency toward anxiety are more likely to experience FAP. Stress at school, home, with friends, or because of a novel social situation may be associated with FAP symptoms (Bishop and Ebach, 2015). Positive and negative reinforcement can modify the pain. NR 602 Childhood Functional Abdominal Pain.

Approximately 15% to 35% of children worldwide have recurrent abdominal pain with about one third of those having no specific organic disorder (Gottsegen, 2010). FAP is the most common pain complaint of preschoolers and accounts for 2% of pediatric visits (Scheffer, 2011). The peak incidence of FAP occurs between 7 and 12 years old (Bishop and Ebach, 2015).

Acute Diarrhea

The term acute gastroenteritis was formerly used to describe acute diarrhea, but this term is technically a misnomer because the etiology of diarrhea does not technically involve the stomach (Guandalini and Assiri, 2014). With acute diarrhea, there is a disruption of the normal intestinal net absorptive versus secretory mechanisms of fluids and electrolytes, resulting in excessive loss of fluid into the intestinal lumen. This can lead to dehydration, electrolyte imbalance, and in severe cases, death in those also malnourished. In children younger than 2 years old, this translates to a daily stool volume of more than 10?mL/kg (this definition excludes the normal breastfeeding stooling of five or six stools per day). In children older than 2 years old, diarrheal stooling is described as occurring four or more times in 24 hours. The duration can last up to 14 days.

876 NR 602 Childhood Functional Abdominal Pain

Viruses can injure the absorptive surface of mature villous cells, which reduces the amount of fluid absorbed. Some can release a viral enterotoxin (e.g., rotavirus). A loss of water and electrolytes ensues, and there can be volumes of watery diarrhea, even if the child is not being fed. Bacterial and parasitic agents can adhere and/or translocate, causing noninflammatory diarrhea. Bacteria can also damage the anatomy and functional ability of the intestinal mucosa by direct invasion. Some bacteria release endotoxins, whereas others release cytotoxins that result in the excretion of fluid, protein, and cells into the intestinal lumen and an inflammatory response in some cases. Abnormal peristalsis for any reason can result in acute diarrhea. The enteric pathogens are spread through the fecal-oral route and by ingestion of contaminated food or water.

Worldwide, the burden of acute diarrhea is huge, resulting in 3 to 5 billion cases and nearly 2 billion deaths (20% of total child deaths) in children younger than 5 years old (particularly vulnerable) (Bell, 2010; Guandalini and Assiri, 2014; Norman et?al, 2010). Developing countries also see their share of the burden of this disease (approximately 10%), attributable to poor water, sanitation, and hygiene (Norman et?al, 2010). Globally, females have higher rates of Campylobacter species infections and hemolytic uremic syndrome; otherwise the incidence of cases shows no gender preference. Nontyphoidal Salmonella, Shigella, Campylobacter, E. coli organisms (bacteria); rotavirus, norovirus, enteric adenovirus (viruses); and Giardia, Cryptosporidium, and Strongyloides (parasites) cause most disease (Ahmed Bhutta, 2011). Shigella, E. coli, Giardia lamblia, Cryptosporidium parvum, and Entamoeba histolytica are particularly infectious in small amounts. The term “dysentery” is used to indicate infection with specific species of Shigella and Salmonella(e.g., Shigella dysenteriae).

In the United States, those most vulnerable include Native Americans and Native Alaskans, where remote residential locations or living on reservations compomises sanitation and safe water supplies, and where severe rotavirus diarrhea occurs. About 200,000 hospitalizations in the United States occur annually due to diarrheal illness with 300 deaths (Bell, 2010). The most common viral pathogens are noroviruses and rotavirus, followed by adenoviruses and astroviruses. Food-borne bacterial or parasitic diarrheal diseases are most commonly due to Salmonella and Campylobacter species, followed by Shigella, Cryptosporidium, E. coli O157:H7, Yersinia, Listeria, Vibrio (Vibrio cholerae and other species), and Cyclospora species. C. difficile has been associated with pseudomembranous colitis and diarrhea after the use of antibiotics, but it is not the causative agent in most antibiotic-associated diarrhea in children in the United States (Ahmed Bhutta, 2011).

Tables 33-11 and 33-14 discuss the characteristics of diarrheal diseases caused by bacteria, viruses, and parasites that a primary care provider is more likely to encounter and needs to differentiate. Infections due to Cryptosporidium, E. coli O157:H7, Giardia, Listeria, Salmonella, Shigella, and V. cholerae are required to be reported to the CDC. The enteric pathogens encountered more in day care settings include rotavirus, astrovirus, calicivirus, Campylobacter, Shigella, Giardia, and Cryptosporidium species (Guandalini and Assisri, 2014). NR 602 Childhood Functional Abdominal Pain.

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Differential Diagnosis

Diarrhea from viral etiology and antibiotic use are the most common causes of diarrhea in all age groups. Systemic infection is a common cause in infants and children, and food poisoning is a common cause in children and adolescents. Overfeeding should also be considered in infants. Rare causes of acute diarrhea in infants include primary disaccharidase deficiency, Hirschsprung toxic colitis, adrenogenital syndrome, and neonate opiate withdrawal; toxic ingestion in children; and hyperthyroidism in adolescents.

Management

The foundation of all treatment of acute diarrhea is fourfold:

• Restore and maintain hydration and correct/maintain electrolyte and acid-base balance. Oral rehydration with an oral electrolyte solution should be attempted when dehydration is assessed between 3% and 9%. Administer parenteral hydration if necessary for the following: impaired circulation and possible shock, weight less than 4 to 5?kg or a child younger than 3 months old, intractable diarrhea, lethargy, anatomic anomalies, or failure to gain weight or continued weight loss despite oral fluids (see Table 33-3).
• Maintain nutrition. Resume early refeeding because contents of the bowel stimulate the growth of enterocytes and help facilitate mucosal repair following injury (see Table 33-3).
• Prescribe antibiotics prudently. Antibiotics are recommended for acute diarrhea caused by G. lamblia, V. cholerae,and Shigella species and can be considered for infections caused by enteropathogenic E. coli (if infection prolonged), enteroinvasive E. coli, Yersinia for those with sickle cell disease, and Salmonella in young infants with fever or positive blood culture findings (Guandalini and Assiri, 2014) (see Tables 33-11 and 33-12). Children with HIV at risk for acute diarrhea may benefit from cotrimoxazole and vitamin A (Humphreys et?al, 2010).