MIAMI — Outcomes are optimized when a biopsychosocial approach is used to manage children with functional abdominal pain, according to Dr. Basil J. Zitelli.

Acknowledge the patient's perceptions of their own well-being and that the “pain is real,” he said. Also recognize that negative clinical tests do not invalidate a child's perception of the illness.

Try to identify the location and cause of the pain, rule out other possible causes, and counsel the patient and family throughout the disease process, said Dr. Zitelli, chief of the Paul C. Gaffney Diagnostic Referral Service at the Children's Hospital of Pittsburgh and professor of pediatrics at the University of Pittsburgh.

In addition, educate parents that their own anxiety can worsen a functional gastrointestinal disorder (FGID) in their child.

The following clinical red flags, diagnostic criteria, and conditions that indicate when referral to a specialist may be warranted were among the tips Dr. Zitelli offered attendees at the pediatric update:

▸ Red flags or FGID alarm symptoms include multiple organ involvement, gastrointestinal bleeding, weight loss, mouth ulcers, and liver disease.

▸ The location of pain can be another red flag. In general, pain that is periumbicular in children younger than 8 years suggests FGID. The farther away from the umbilicus, the greater the chance of underlying disease, Dr. Zitelli noted.

▸ If the pain is epigastric, the stomach, esophagus, duodenum, or pancreas may be involved; there may also be dyspepsia and/or Helicobacter pylori involvement.

▸ Right upper quadrant pain suggests hepatobiliary disease or involvement of the pancreas head.

▸ Right lower quadrant pain suggests the appendix, cecum, ovary, and/or rectosigmoid may be involved. Such pain also points to irritable bowel syndrome (IBS).

▸ Left lower quadrant pain also suggests rectosigmoid involvement and IBS, as well as pain caused by ulcerative colitis.

“I also do a rectal examination looking for fissures, tags, or other abnormalities,” Dr. Zitelli said.

Take a detailed family history specific to GI disorders, he advised. Also ask about any initiating events or exacerbating factors for the patient. For example, is the pain associated with eating or defecation? Has there been difficulty in the home—a loss of a family member or marital discord? Has there been any abuse or violence inflicted upon or directly observed by the child?

Before the release of Rome III criteria in 2006, the bias used to be that FGID was “not real,” was “in your head,” or was “nonorganic,” said Dr. Zitelli.

The Rome III criteria allow for more specific diagnoses. The criteria classify pediatric FGID into functional abdominal pain, functional dyspepsia, IBS, and abdominal migraine. Pain has to occur at least once a week for 2 months or more to meet the criteria. The exception is abdominal migraine, where more than two episodes in 12 months are required.

“Abdominal migraine is different, paroxysmal, acute, severe, noncolicky, and periumbicular pain lasting several hours,” Dr. Zitelli said. A patient can have anorexia, nausea/vomiting, and pallor and be healthy between episodes. “This is important,” he noted.

Helpful tests include a complete blood count, erythrocyte sedimentation rate, and C-reactive protein (CRP) assay. However, Dr. Zitelli said, “CRP may not be elevated in patients with ulcerative colitis or a large percentage of children with Crohn's disease.” If specifically indicated, additional tests for transaminases, lipase, celiac studies, and urinalysis may be useful.

However, it is important to avoid overtesting, Dr. Zitelli said. “There is a temptation to do test after test after test. We must be careful as physicians not to become part of the pathologic process by endless testing.” He added that “if FGID [diagnosis] can be made using Rome III criteria, no extensive labs are needed.”

A trial of empiric therapy can be initiated, Dr. Zitelli said. For example, a 2-week trial of a proton pump inhibitor or H₂ blocker for a child with upper abdominal pain or polyethylene glycol 3350 for the child with lower abdominal pain may be indicated.

A low-lactose diet, low-fructose diet, and addition of dietary fiber are other possible interventions. Also consider use of complementary or alternative medicines, but “make sure they are safe and only adjunctive therapies,” he said.

Antidepressants may be of some value. For example, tricyclic antidepressants can modulate pain, can alter mood, and may enhance gastrointestinal motility. So they could be helpful for those with constipation.

“If there is no improvement, referral to a pediatric specialist may be warranted,” Dr. Zitelli said.

Many of the recommendations Dr. Zitelli provided are summarized in reports in the May 2009 Pediatric Annals (for example, 38:241-2, 253-8, 279-82). He recommended that pediatricians review this issue for additional information and guidance on FGID.

Disclosures: Dr. Zitelli disclosed that he receives royalties from Elsevier for book publishing.

For more information on the pediatric Rome III Criteria, visit www.romecriteria.org

Functional Abdominal Pain in Children: What to Watch for