1. Functional pain in childhood ד"ר דקלה אגור, ד"ר מוניקה קראוס, ד"ר אירנה שטיינפלד המחלקה לרפואת משפחה חיפה

2. Girl age 8 ליהי בת 8, כאבי בטן חוזרים מאז ספטמבר. כאבים הגורמים להחמיץ ימי לימודים. לאחרונה החמרה בעוצמת הכאב. שני ההורים עובדים, עד עכשיו קבלו את כאבי הבטן כ " תופעה חולפת " אך עתה מבקשים Reassurance.

3. 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

4. Other names Rome 111 criteria: functional dyspepsia Irritable bowel syndrome Functional abdominal pain Abdominal migraine

6. Prevalence: Community based studies vary from 0.5 – 19% Age peaks: 4- 6 years and 7 – 12 Are girls more likely to be affected?

7. Is it all helicobacter? Lin et al: 2006, Hepatogastroenterology 53 (72) 883-6 (Taiwan) 135 patients with FAP All endoscoped, urease breath tests: 43.7% normal 19.3% Esophagitis 13.3 peptic ulcer, 7.4% gastritis. 23.7% had evidence of helicobacter infection

8. 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

9. 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

10. Making the diagnosis confidently History and examination Talk to the child Exacerbating factors? Relieving factors? Acknowledge distress

11. Making the diagnosis confidently No diagnostic tools BUT absence of ‘alarm factors’ (American Academy : Paediatrics 2005) Involuntary weight loss Poor linear growth GI blood loss Significant vomiting Chronic severe diarrhoea Unexplained fever FH of inflammatory bowel disease

12. 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

13. 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

14. 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

15. Unlikely to be related: Pain characteristics, frequency, severity Depression Lactose malabsorbtion

16. 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

17. 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

18. Management Validate the child’s experience Explore the family’s understanding and beliefs of abdominal pain May need to do some tests to reassure child and family – but resist over investigation Explain the link between emotions and visceral symptoms – ‘holistic view’

19. Using a diary Ask CHILD to keep a pain diary ‘being a detective’ Score 0-5 Review diary with child

20. Evaluating treatments: Cognitive behaviour therapy – 3 randomized trials showed benefit Peppermint oil – may help Role of pizotifen (Sanomigran ® ) ?? More research needed!

21. Our patient: High academic achiever Conscientious and anxious to do well Scary teacher Pain worse on needlework lesson days…..

22. When to investigate If ‘alarm’ symptoms If pain not typical – e.g. in the renal area. US may show obstruction If there are family health beliefs

23. And its all food allergy, doc…. Make sure the diet is ‘safe’ Explain the limitation of allergy testing Discuss celiac disease Encourage ‘food challenges’ to reintroduce food into the diet

24. נועה בת 12 ש ' מתלוננת בחודשים האחרונים על כאב ראש 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.

25. Epidemiology of Headache Most common cause of childhood pain Uncommon before4 years Uncommon before 4 years Prevalence of all types increases with age Prevalence of all types increases with age < 10-12 yearsmale:female 1 : 1 < 10-12 years equal among sexes, male:female 1 : 1  > 10-12 yearsgirls 1.5  > 10-12 years greater prevalence in girls (1 : 1.5) MIGRAINETENSION most are MIGRAINE or TENSION remission occurs in 70%ages 9-16 years remission occurs in 70% of cases ages 9-16 years  1/3 remain headache free after 6 years, 2/3 remain headache free after 16 years

26. Classification of Headache  PRIMARY= Benign (Migraine, Tension, Cluster)  PRIMARY = Benign (Migraine, Tension, Cluster)  exam normal  no papilledema  normal neuroimaging  no fever / meningismus, normal CSF  SECONDARY = malignant, symptomatic  Something’s wrong

27. Migraine  Genetic predisposition“classic”  Genetic predisposition, esp. “classic” with aura  “Common”  “Common” without aura - 70-85 % children  Triggers  Triggers: sleep deprived, hunger, illness, travel, stress (only 50 % migraineurs can identify trigger)  Frontotemporal pain  Frontotemporal pain (anterior, uni- or bilateral)  Autonomic symptoms  Autonomic symptoms:  Nausea/vomiting or photo-/phonophobia, pallor aura  May be preceded by transient aura (< 1 hr, 15-30 min )  Visual aura most common

28. migraines Association of migraines in children with other conditions:  Somatic pain complaints  Abdominal (diffuse non-localizing crampiness) epileptic  8-15 % epileptic children psychiatrically ill  21 % psychiatrically ill children  major depression  panic attacks or other anxiety disorder

29. Migraine-related syndromes (variants)  Benign paroxysmal vertigo  recurrent stereotyped bouts of vertigo  often with nausea, vomiting, nystagmus  Cyclic vomiting  recurrent severe sudden nausea and vomiting  attacks last hours to days  symptom-free between attacks

30. posteriorband-like  Pain typically posterior > anterior, or band-like  Squeezing  Squeezing quality (tight, vice-like)  Neck muscles sore STRESS !  Common trigger: STRESS !  NO  NO autonomic symptoms  NO nausea/vomiting or photo/phonophobia  NO  NO aura  Best treatments:  NSAIDs, relaxation / biofeedback Tension headache

31. 5+ week 5+ per week 15+ month 15+ per month No underlying pathology No underlying pathology Migraines changed character: Migraines that have changed character:  Poor pain control  Psychosocial causes  Medication overuse  Medication overuse (“rebound headaches”) “Chronic Daily Headaches”

32. minimizetriggers (MIGRAINES)  Avoid / minimize 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) minimize stress  Mind-Body approach - minimize stress  Biofeedback / relaxation, Self-hypnosis  Acupuncture Treatment for primary recurrent headache

33. same location  headache is always in the same location  focal neurologic findings  focal neurologic findings appear (in first 2-6 m)  VI n. palsy, diplopia, new onset strabismus, papilledema  Hemiparesis, ataxia  progressively increasing  progressively increasing frequency / severity of headache, headache worse with valsalva awakens from sleep, worse in the morning, AM vomiting  headache awakens from sleep, worse in the morning, AM vomiting  at-risk hx or condition:  at-risk hx or condition: VPS, neurocutaneous disorder Rethink the diagnosis of benign headache:

34. BEING POSITIVE! Functional pain in childhood