Motilin in children with recurrent abdominal pain: a controlled study

Fjord Christensen M. Motilin in children with recurrent abdominal pain: a controlled study. Aeta Pædiatr 1994;83:542–4. Stockholm. ISSN 0803–5253
The aim of this study was to compare serum motilin levels in children with and without recurrent abdominal pain, based on the assumption that recurrent abdominal pain in children is a gut motility disorder. In this controlled study, 19 children between 6 and 15 years or age with recurrent non-organic abdominal pain and 20 control children between 6 and 15 years of age without abdominal pain or other functional somatic complaints were evaluated. No slatistical significant difference was found in serum motilin levels between children with and without abdominal pain. Median difference between the groups was II pmol/1 (95% confidence limits of median difference -9 to +33). This investigation could not support the assumption that motilin might be a pathogenic factor in children with recurrent abdominal pain. It is suggested, however, that future research should compare serum motilin levels during and between attacks of pain.     

Principles of managing children with asthma in the emergency department

INTRODUCTION

Paediatric asthma exacerbations comprise a significant portion of emergency department (ED) visits and hospitalizations. Recognition of diagnostic symptoms and signs, and timely use of appropriate medications may reduce the need of hospitalizations and the impact of this disease on the lives of children and their families.

OBJECTIVE

To review the pathophysiology of asthma, the current recommendations for conventional medical treatment in the ED, the controversies surrounding adjunct therapies, and the importance of discharge planning and follow-up.

CONCLUSIONS

Paediatric asthma exacerbations may be successfully treated in the ED with the use of appropriate inhaled and systemic medications.     

Procedural sedation and analgesia for paediatric patients in the emergency department

Children presenting to the emergency department (ED) often require sedation for brief procedures such as fracture and dislocation reductions, laceration repairs, and imaging procedures that are painful, anxiety provoking or both. This article presents three cases of paediatric patients who require sedation and/or analgesia, and summarizes important aspects of procedural sedation for the primary care practitioner in the emergency setting. Presedation assessment and monitoring equipment are detailed. Discussion of routes of administration and different agents including barbiturates, opiates, benzodiaxepines, the ‘cardiac coctail’, ketamine, propofol, nitrous oxide, and etomidate follow. Emphasis is placed on indications, contraindications, dosing, timing and advantages and disadvantages of each. Reversal agents are mentioned, and discharge criteria are outlined.     

The management of acute abdominal pain in children

Objective : Acute abdominal pain is a common problem in childhood, and appendicitis is frequently diagnosed by general practitioners and doctors working in emergency departments. The objective of the present report was to determine the frequency of appendicitis in a group of children with acute abdominal pain presenting to the emergency department of a general hospital, as well as attempting to analyse the manner in which these patients were managed.
Methodology : The initial assessment in hospital (by resident hospital staff) of the study group of patients was analysed and their subsequent clinical progress documented.
Results : The present report shows that the vast majority of children with acute abdominal pain do not have appendicitis and that appendicitis is significantly over-diagnosed by junior hospital doctors.
Conclusions : Appendicitis is a clinical diagnosis, best made by an experienced member of the paediatric surgical team. Frequent review, with a minimum of investigations, provides the best means of making a rational decision regarding surgery.     

Bacteremia in feverish children presenting to the emergency department: a retrospective study and literature review

Aim: To evaluate the incidence of bacteremia, and the isolated pathogens, in well‐appearing children with fever without source (FWS) presenting to the pediatric emergency department (PED), after pneumococcal conjucate vaccine ‐ 7 valent (PCV‐7) widespread introduction in the Veneto region of north‐eastern Italy, and to review the main literature contributions on the subject. Methods: Blood cultures performed at the PED of Padova from 1 June 2006 to 31 January 2009 in febrile children aged 1–36 months were retrospectively retrieved. Medical records of previously healthy well‐appearing children with FWS were identified and reviewed. Results: The study finally included 392 patients. Bacteremia rate was 0.34% (95% CI 0–1) in the age group 3–36 months and 2% (95% CI 0–4.7) in infants 1–3 months. No Streptococcus pneumoniae was isolated. The literature review identified 10 relevant studies carried out in the USA and Spain showing an overall bacteremia rate <1% for feverish children aged 3–36 months, with values <0.5% in settings with high PCV‐7 coverage. Conclusion: Overall bacteremia rate is currently <0.5% in well‐appearing children aged 3–36 months with FWS attending the PED in areas with PCV‐7 widespread vaccination and is sufficiently low to preclude laboratory testing in favour of close follow‐up. Further research is needed to evaluate a more conservative approach in infants 2–3 months of age.     

С������֢�ĸ�ʹ�ص�

??Sudden and violent abdominal pain with comparatively fixed location should be clinical features in children with acute abdominal diseases. The constant development of system and organs in childhood makes it difficult for pediatricians to make correct diagnosis of pediatric acute abdomen. Complete inspection and particularly abdominal palpation and digital examination should be emphasized. Correct understanding of abdominal pain in children with acute abdominal diseases is of critical importance.     

Procedural pain in a paediatric surgical emergency unit

Pain induced by various types of procedures was assessed in the Paediatric Surgical Emergency Department at St Göran's Children's Hospital in Stockholm. Assessments of pain were obtained from the nurse, the parent, and children over 10 years of age by means of a visual analogue scale. In children aged 3–9 years, the Smiley Five-Face Scale was used. The nurse and the parent also answered questionnaires about analgesic medication, the child's behaviour, and the parent's overall opinion of the pain management, etc. Irrigation of the glans penis because of balanitis, treatment of fractures and paronychia were considered to be the most painful procedures. Forty-four per cent of the children cried during the procedure and 16% fought against being restrained. In 24% of the cases, the child was judged to be in a state of "panic". In conclusion, we believe that the pain induced by procedures in the emergency rooms is unacceptably high. Children estimate higher pain scores than parents and nurses do. There was a poor correlation between the parent's and child's estimates of pain. Parents are not well informed about the possibilities for pain treatment. Infants and children attending emergency rooms must also benefit from recent advances in the treatment of pain.     

Irritable bowel syndrome: the commonest cause of recurrent abdominal pain in children

Apley, working in Bristol, UK, defined recurrent abdominal pain (RAP) in 1958. After extensive investigations, he found that 8% of children presenting to his clinic with RAP had an organic pathology. The aims of this study were to identify (1) causes of RAP using modern methodology, (2) factors associated with organic RAP and (3) children with none-organic RAP who fulfill the diagnostic criteria for irritable bowel syndrome (IBS). Children, aged over 3 years, presenting with RAP were prospectively recruited to this study. They had a detailed questionnaire completed, a full examination with screening tests (blood for coeliac screen, Helicobacter pylori antibody titre, inflammatory markers, serum amylase, liver function tests, and full blood count, urine and stool analyses and abdominal ultrasonography). Endoscopy and oesophageal pH monitoring were performed if clinically indicated. IBS was diagnosed if the child had no organic pathology and fulfilled the Rome II criteria. Out of 103 children (median age of 10 years, mean 10.04, SD ±3.44,), 31 children (30%) had organic pathologies. Factors associated with organic pain were nocturnal symptoms (P<0. 01) and abdominal tenderness (P<0.005) and with non-organic pain were periumbilical locality (P<0.002), pain alleviation on defaecation (P<0.04) and low fibre diet (P<0.005). Of children with non-organic pain, 37/52 (51%) fulfilled the criteria for IBS (36% of the total). Conclusion:of children presenting with recurrent abdominal pain in a hospital setting, 30% have a diagnosable organic aetiology compared to 8% in Apleys time. Irritable bowel syndrome, however, may be the commonest cause of recurrent abdominal pain and should be considered.Abbreviations CRP C-reactive protein - GORD gastro-oesophageal reflux disease - IBS irritable bowel syndrome - RAP recurrent abdominal pain     

Abdominal ultrasonography in the diagnostic work-up in children with recurrent abdominal pain

We report on our experience with routine abdominal ultrasonography in 120 children (aged 3–15 years) with recurrent abdominal pain, in order to determine the diagnostic value of this investigation. Eight children (7%) revealed sonographic abnormalities: gallbladder stone (n = 2), splenomegaly (n = 1) and urogenital abnormalities (n = 5). The recurrent abdominal pain could be explained by these findings in only two (may be three) cases. Conclusion The diagnostic value of abdominal ultra‐sonography in unselected children with recurrent abdominal pain is low. However, the direct visualization of the abdominal structures as being normal may be helpful to the parents and the child in their understanding and acceptance of the benign nature of recurrent abdominal pain. Received: 19 March 1996 / Accepted: 29 January 1997     

Recurrent abdominal pain and Helicobacter pylori in a community-based sample of London children

Helicobacter pylori is accepted as an important factor in the pathogenesis of peptic ulcer disease. Infection is probably most commonly acquired in early life but there is still limited information on the prevalence or symptomatology of H. pylori infection in childhood. The aim of the present study was to establish the prevalence of H. pylori infection in a large sample of urban school children and to determine its relationship, if any, to a history of recurrent abdominal pain. Using a commercial ELISA significant levels of anti- H , pylori IgG antibody were detected in 107/640 (16.7%) of school children (M, 383; F, 257; mean age 9.15 years, range 4-13). No relationship was demonstrated between H. pylori seropositivity and a personal or family history of recurrent abdominal pain or the nature of the pain.     

Recurrent abdominal pain in school children: effect of obesity and diet

AIMS: To study the epidemiology and some of the risk factors of childhood recurrent abdominal pain (RAP) in school age children. METHODS: We used a questionnaire concerning socioeconomic parameters, intensity, frequency, duration, nature of RAP and anthropometric measures. We used several criteria to identify RAP and the Wong-Baker FACES scale for pain intensity and calculated the gender/age-specific body mass index (BMI) Z-score using NCHS standards. Obesity was defined as a BMI>or=95th percentile for age and gender. RESULTS: A total of 925 children mean age of 9.5 years completed and returned the questionnaires. The prevalence of RAP was 24%; 22% among boys versus 26% among girls (p=0.28) and reached its peak among children aged 7-9 (29%) years. Children with BMI>or=95% percentile reported more RAP compared to those not obese (33.3% vs. 22.5%) (OR=1.8, p=0.01). There was an inverse correlation between fruit consumption and RAP prevalence with 20% among children reporting more than three serving of fruit per week compared to 40% of those who did not consume any fruits (p<0.002). Logistic regression analysis confirmed BMI>or=95th percentile and low consumption of fruits are significant risk factors for RAP. CONCLUSIONS: There is a significant association between RAP and obesity and both conditions are prevalent among children in this population. Understanding more about the co-morbidity between RAP and obesity could have important implications on RAP management and treatment.     

The prevalence and related symptomatology of Helicobacter pylori in children with recurrent abdominal pain

The aim of the study was to assess and compare the IgG seroprevalence of H. pylori in children with recurrent abdominal pain with healthy children and to investigate the related symptoms. IgG antibodies against low-molecular weight H. pylori antigens were assessed in 438 children with recurrent abdominal pain and in 91 healthy controls. Sera with an ELISA unit-value above the cut-off level were confirmed by Western immunoblot. Only seropositive children with recurrent abdominal pain were examined by an oesophago-gastro-duodenoscopy. Symptomatology was recorded according to the localization of the abdominal pain, presence of pyrosis, nocturnal pain, relation of pain to meals and bowel irregularities. The seroprevalence was 21% (95% CI: 17-25%) in the children with recurrent abdominal pain and 10% (95% CI: 5–18%) in the healthy controls ( p = 0:30). In seropositive children with RAP H. pylori was found in 46/66 by culture and histology. The presence of H. pylori was significantly associated with active or inactive chronic gastritis. The presence of H. pylori was associated with both parents being born in a country with a high prevalence and a low social class. Helicobacter pylori-positive children had more often pain related to meals than the H. pylori- negative children. No differences among the two groups were seen according to the levels of haemoglobin, leucocytes, thrombocytes, weight and height. In conclusion, the seroprevalence of H. pylori is comparable in children with recurrent abdominal pain and healthy children. No specific symptomatology was seen in H. pylori- positive children with RAP.     

Lactose and fructose malabsorption in children with recurrent abdominal pain: results of double-blinded testing

Aim: To investigate malabsorption of lactose and fructose as causes of recurrent abdominal pain (RAP). Methods: In 220 children (128 girls, mean age 8,8 [4.1–16.0] years) with RAP, hydrogen breath tests (H₂BT; abnormal if ΔH₂ > 30 ppm) were performed with lactose and fructose. Disappearance of RAP with elimination, recurrence with provocation and disappearance with re‐elimination, followed by a 6‐month pain‐free follow‐up, were considered indicative of a causal relation with RAP. For definite proof, a double‐blinded placebo‐controlled (DBPC) provocation was performed. Results: Malabsorption of lactose was found in 57 of 210, of fructose in 79 of 121 patients. Pain disappeared upon elimination in 24/38 patients with lactose malabsorption, and in 32/49 with fructose malabsorption. Open provocation with lactose and fructose was positive in 7/23 and 13/31 patients. DBPC provocation in 6/7 and 8/13 patients was negative in all. However, several children continued to report abdominal symptoms upon intake of milk or fructose. Conclusion: Lactose intolerance nor fructose intolerance could be established as causes of RAP, according to preset criteria including elimination, open provocation and DBPC provocation. However, in clinical practice, persistent feeling of intolerance in some patients should be taken seriously and could warrant extended elimination with repeated challenges.     

Recurrent abdominal pain in children: a long term follow-up

A long-term follow-up study (minimum of 10 years) of 16 children admitted for recurrent abdominal pain revealed that in 50% of the sample the disturbance disappeared completely, persisted in 25% and in the remaining 25% other painful symptoms developed. The variables that characterized the poor outcome group were: belonging to a painful family, many surgical procedures, low educational level and social class and a low score in the Q3 factor of the Sixteen Personality Factor Questionnaire (spare capacity to control emotions).Abbreviations RAP recurrent abdominal pain - SDS self-rating depression scale - 16 PF Sixteen Personality Factor Questionnaire - SD standard deviation - Q quartile     

Gastroesophageal reflux in children with recurrent abdominal pain

In this study we investigated the presence of gastroesophageal reflux in children with recurrent abdominal pain and its possible relationship to food intolerance-associated duodenal inflammation. Twenty-four-hour intra-esophageal pH monitoring, an endoscopic duodenal biopsy and a small bowel 51Cr-EDTA permeability test were performed in 25 children with recurrent abdominal pain. In 14 cases (56%) the pH monitoring was abnormal, pointing to the presence of pathological gastroesophageal reflux. Treatment of gastroesophageal reflux in the latter patients resulted in resolution or improvement of abdominal pain in 10 cases (71%). Gastroesophageal reflux did not appear to be associated with either intestinal permeability to 51Cr-EDTA or duodenal biopsy findings. We conclude that pathological gastroesophageal reflex is a frequent finding in children with recurrent abdominal pain, that it is unrelated to duodenal inflammation and that there might be a causal relationship between pathological gastroesophageal reflux and recurrent abdominal pain in children.