Most paediatricians enjoy looking after children. In order to be a good paediatrician, one has to have the same qualities required of a good parent – and patience has to be at the top of that list of requirements. Looking after a child with chronic, persistent abdominal pain is a common problem requiring a big dose of patience.
Just how common is this problem? Common enough that it is hardly possible for an average-sized paediatric practise to function without seeing at least one case of recurrent abdominal pain every alternative day. Frequently, these patients tend to be female; often in their preteen years; they are driven, perfectionists and have sensitive personalities. The problem may get so bad that the child misses school, drops out of extracurricular activities, sees more than one specialist, tries alternative remedies out of sheer frustration and ends up getting worse and worse instead of better. The stress this places on the family, the school, marital harmony and most of all the child reminds me of bookshelves buckling under the heavy weight of too many books.
The diagnosis of a child with so-called recurrent abdominal pain, also described as functional abdominal pain by some, cannot be made unless a good and thorough assessment has taken place. This indeed is a diagnosis of exclusion. With that in mind a parent has to become a fellow spy in paying closer attention to the child’s symptom pattern. Keeping a diary of symptoms helps a great deal. Experts from the academic world tell us that the abdominal pain can be followed over time in a calm reassuring, but regular fashion, if it has this pattern:
there is no loss of weight. there is no vomiting on a consistent basis. there is no regular nighttime symptoms severe enough to wake the child up there is no blood in the stools.
The diagnosis of recurrent abdominal pain should be discarded if any of the above symptoms surface.
I am fascinated by this common childhood condition, because it illustrates how the body and mind can interact --- the so-called mind/body connection. Why, for example does our gastrointestinal tract so often take centre stage when we are under stress? Why not the big toe? Why not the earlobe? We do not know why functional abdominal pain occurs, for sure. My academic colleagues are still looking for the smoking gun and probably will continue to add to an already impressive list of possible reasons and theories.
Certain things do not help though: constipation; a low fibre diet; a teacher who is harsh; divorce in the family; a demanding athletic coach or music teacher; bullying ; and a perfectionist attitude in both the patients and the parents.
Where can parents find help when this painful challenge starts to toss the family against the rocks? As always, education is the most important foundation. It helps to have a caring and supportive physician. That is rarely enough though. Further reading is recommended and a number of good books are available(Dr Apley wrote a book for doctors on this topic and
although it may be highly technical, there are good references linking a reader to other resources. The American Academy of Pediatrics has further information at www.aap. org. The Canadian Paediatric Society offers further education at www.cps.ca) For the worst cases one should consider the use of pain specialists and or psychologists.
Given the recent media attention to appendicitis and how it may often present like a chameleon---in many different colours---and thus lead to complications, it comes as no surprise that a diligent parent would be worried about a mis-diagnoses appendicitis. If there is one thing to
remember though, it would be this: the pain associated with appendicitis very very rarely comes and goes. Instead, it tends to get progressively worse and it is mostly associated with other symptoms such as vomiting, fever loss of appetite or pain over the area where the appendix is located(half way between the belly button and the right hip bone).
In medicine we are taught to never say never. Yet I have never seen a child with chronic abdominal pain who cannot be followed closely, but with reassurance as long as there is no vomiting, night time symptoms, blood in the stool or weight loss. Meanwhile these children should be taken seriously but at the same time managed in a firm and caring way--- they should not be allowed to use their symptoms, unfortunate as it may be, to manipulate those around them. Finally, my advice to parents are that they should always do their best, but whatever I may tell them, I will never be able to do what time so often does to a child with recurrent abdominal pain: it heals.
Access www.healthykids.ca for a terrific new resource in helping families raise healthy children - HealthyKids with Dr. Nieman will optimize your child's complete health.
An informed parent is ... an empowered parent.