Exploratory laparoscopy for recurrent right lower quadrant pain in a pediatric population

Recurrent or chronic abdominal pain can be a challenging problem when conventional diagnostic studies fail to identify the cause. It is estimated that up to one-third of children suffer from abdominal pain, and in this population recurrent pain can be even more challenging. Although recurrent right lower quadrant (RLQ) or periumbilical pain may be attributed to chronic appendicitis, this diagnosis remains controversial. Our aim was to evaluate pediatric patients who had undergone laparoscopic exploration for chronic RLQ abdominal pain to determine their histologic diagnosis, etiology of pain, and contributing factors that may predict a positive outcome. Patients with abdominal pain greater than 1 month in duration who ultimately underwent laparoscopic exploration and appendectomy were included in the study. Patients were excluded if an identified source of pain was discovered during preoperative workup, or if postoperative follow-up was less than 2 years. Intraoperative findings were noted, and all specimens were histologically examined with additional, subsequent independent review. Pertinent findings from preoperative diagnostic tests, mental health history, and pre and postoperative symptomatology were noted. Patient outcomes were recorded at the time of follow-up and after 2 years to assess resolution of their symptoms. Of the 44 patients studied, 31 (70.5%) had partial or complete resolution of symptoms at 2 years. Thirteen (29.5%) continued to have pain. Twenty-eight patients (63.6%) had abnormal histology identified on appendiceal examination, and 14 had other abnormalities found at laparoscopy (31.8%). Eighteen patients were being treated for psychiatric diagnosis, and 21 suffered from chronic headaches. There were no long-term complications from surgery. Long-term follow-up revealed that 70% reported complete or partial relief of their RLQ pain at 2 years. No factors were identified that may be helpful in predicating outcome in this population. While exploration was beneficial for a majority of this population, patients and parents should be warned that this intervention might not provide the relief of symptoms or provide the diagnostic answer to their pain.     

Psychiatric approach in the treatment of reflex sympathetic dystrophy in an adolescent girl: a case report

Reflex sympathetic dystrophy (RSD) is an unusual diagnosis in the pediatric age group. It is a syndrome characterized by pain in one or more extremities with a significant morbidity in childhood. Patients with RSD have frequently undergone many unnecessary investigations such that the diagnosis and treatment may be considerably delayed. The pathophysiology remains unclear; however, a number of psychological problems were frequently suggested to play a role in this disorder. We describe a 13-year-old girl diagnosed as pediatric RSD who was admitted to a child and adolescent psychiatry unit with a history of severe pain in the right hand, increasing disability and symptoms of nervousness and withdrawal from social activities. In this report, we discuss psychogenic factors underlying the disorder of an adolescent girl and psychiatric approach as a part of a multimodal treatment of pediatric RSD.     

Psychiatric symptoms of adolescents reared in an orphanage in Ankara

This study compared male adolescents in an orphanage with adolescents raised by their families in terms of psychiatric symptoms, using the Brief Symptom Inventory. Anxiety, depression, negative self, hostility, and Global Severity Index points were significantly higher in adolescents in the orphanage, although they did not reach pathological levels except with respect to hostility. Adolescents reared in orphanages scored high points for hostility, reaching pathological levels.     

Tension-type headache in children: A clinical evaluation

BACKGROUND: Headache Society (IHS) criteria for episodic tension-type headache were included in the present study. Pain characteristics, associated symptoms, and stress-triggering factors were evaluated. Psychiatric and psychosocial evaluations were performed according to DSM-IV criteria. RESULTS: Pain was bilateral in 93.7% of patients and bitemporal in 50% of children. The intensity of pain increased with motion and stress in more than half of the patients, while pain decreased with rest and massage in 43.7% of patients. Ten of the 16 (62.5%) patients were diagnosed as having a psychiatric disorder. The most common stress-triggering factors were difficulty in adaptation at school and relationship problems with family members. All of the children reported 26 stress factors. Of these stress factors, 20 (76.9%) were reported by children diagnosed with psychiatric disorder. CONCLUSION: These results suggest that in children with tension-type headache a thorough psychiatric evaluation should be performed to rule out underlying psychiatric disorders.     

Visceral pain-associated disability syndrome: a descriptive analysis

OBJECTIVE: Pain-associated disability syndrome (PADS) is a recently defined term that describes patients with chronic pain whose restriction in daily activities appears disproportionately severe for the observable pathology. The aim of this study is to describe the features of a group of pediatric patients with abdominal symptoms fitting this diagnosis. METHODS: To identify factors associated with visceral PADS, we reviewed the records of 40 patients (18 males; age range, 7-21 years) with gastrointestinal symptoms severe enough to prevent school attendance or eating for 2 months or more. These patients, in whom pain was neither feigned nor self-induced, met the diagnostic criteria for visceral PADS, including failure of usual treatments and lack of a satisfactory organic explanation for the severity of the pain. RESULTS: The dominant symptom was abdominal pain in 30 patients, regurgitation in 5 patients, nausea in 3 patients, and chest pain in 2 patients. All patients complained of pain or discomfort, and all met symptom-based criteria for one or more functional gastrointestinal disorder. Disordered sleep was a problem for 39 patients. Factors associated with PADS included learning disabilities, unrealistic goals in a perfectionist, high-achieving child, early pain experiences, passive or dependent coping style, marital problems in the home, and chronic illness in a parent. All patients had at least two associated factors, and a majority had four or more associated factors. Possible triggering events included an acute febrile illness in 20 patients, school change in 11 patients, trauma in 2 patients, death of a loved one in 2 patients, and sexual abuse in 2 patients. Before diagnosis, all patients underwent extensive negative evaluations. Nearly all patients had mental health evaluations that ruled out eating disorder and psychosis. Medical management had failed, and surgeries worsened symptoms. In a majority of patients, we identified a comorbid psychiatric disorder. CONCLUSIONS: Evaluation of preteens and teens unable to go to school or eat because of unexplained incapacitating symptoms should include queries about factors associated with PADS. To treat PADS, medical and mental health clinicians must recognize pain as having both nociceptive and affective components and address treatment collaboratively. Invasive procedures and surgery reinforce the cycle of arousal and pain and are to be avoided. Age for the onset of PADS in the preteen and early teen years suggests that developmental issues play a role.     

Gallbladder dyskinesia: a cause of chronic abdominal pain in children.

PURPOSE: Gallbladder dyskinesia (GD) is a well-established disorder in adults, but it is not clearly defined in the paediatric population. Therefore, the aim of this study was to review our experience in a group of children with chronic abdominal pain associated with impaired gallbladder emptying in the absence of cholelithiasis. METHODS: The records of sixteen patients who underwent cholecystectomy with the diagnosis of GD were evaluated retrospectively. Clinical presentation, symptoms, diagnostic studies, and the effect of cholecystectomy in alleviating abdominal complaints were investigated. RESULTS: All patients had symptoms of upper abdominal pain in the absence of other attributable causes associated with low gallbladder ejection fractions (GEF) < 35 %, during cholecystokinin-stimulated hepatobiliary scan (CCK-HBS), and free of gallstones on ultrasound (USG). Abdominal pain and nausea were the most common presenting symptoms. Mean GEF was 15.3 %. All patients underwent cholecystectomy. The histopathological diagnoses of all operated patients were consistent with chronic cholecystitis. Symptoms were completely relieved in all except two patients. CONCLUSION: GD should be considered in the differential diagnosis of recurrent abdominal pain in children. Patients with this condition present with biliary-type pain and investigations show no evidence of gallstones in the gallbladder. Performing a CCK-HBS establishes the diagnosis. Patients with an abnormal GEF (< 35 %) should undergo cholecystectomy. This procedure has been shown to be effective in curing the symptoms in over 80 % of patients. To avoid late diagnosis, CCK-HBS should be employed early in the evaluation of biliary colic with negative sonographic findings.     

Chest pain in children referred to a cardiology clinic

One hundred consecutive patients (54 girls, 46 boys) referred to a pediatric cardiology department with the primary complaint of chest pain were evaluated. The age distribution was 2.5–16.0 years (mean 11.3 years for girls and 9.9 years for boys). The history showed 17% of patients with chest pain, 22% with heart disease, and 19% with recent death in the family. The time course of the pain was longer than 1 week in 92 patients. Localization was on the left precordium in 60 patients, and there was no radiation from the original site in 66 cases. Ninety-two percent of cases were idiopathic in origin. Of the 74 patients who had a psychiatric interview, 55 (74%) had psychiatric symptoms and 5 required psychiatric care. Anxiety, conversion disorder, and depression were the main psychiatric symptoms.     

Parent–child hostility and child ADHD symptoms: a genetically sensitive and longitudinal analysis

Background:  Families of children with attention-deficit/hyperactivity disorder (ADHD) report higher rates of conflict within the family and more negative parent–child relationships. This study aimed to test whether negative parent–child relationships have a risk effect on ADHD symptoms using two complementary designs.
Method:  The first sample included 886 twin pairs, aged 11–17 years, derived from a population-based twin study. The second sample was derived from a longitudinal community study and included 282 parents and their children, aged 11–14 years. Questionnaires were used to assess ADHD symptoms and hostility in the mother–child and father–child relationship. Bivariate genetic analysis was used to test the contribution of genetic and environmental factors to the association between parent–child hostility and ADHD symptoms in the twin sample. Cross-lagged and reciprocal effects models were used to test for a bidirectional relationship between parent–child hostility and ADHD symptoms over time in the longitudinal study.
Results:  For boys, both genetic and environmental factors contributed to the link between mother–son hostility and ADHD symptoms, but genetic factors alone explained the association between father–son hostility and ADHD symptoms. For girls, the association between ADHD symptoms and mother–daughter hostility as well as father–child hostility was attributed to genetic factors alone. The longitudinal study provided evidence of boys' ADHD symptoms impacting upon mother–son hostility both within and across time. There were no effects in the opposite direction.
Conclusions:  A causal hypothesis of family relations influencing ADHD symptoms was not supported. Boys' ADHD symptoms appear to have an environmentally mediated impact upon mother–son hostility.     

Stressful life events and somatic complaints in adolescents

Although life stress has often been associated with recurrent pain in children and adolescents, level of stress has not previously been found useful in differentiating patients with functional pain from those in whom other conditions are diagnosed. In this study, a standard measure of stressful life events was systematically administered to 172 adolescents seen for the first time at an outpatient adolescent clinic. Patients with recurrent pain for which no organic etiology could be identified reported significantly higher life stress than patients being seen for routine checkup, acute minor illness, stable chronic illness, or pain with clinically diagnosed organic cause. Furthermore, patients referred for behavior problems indicated significantly higher life stress than all other patient groups. It is suggested that a measure of stressful life events may be a useful adjunct to the clinical interview and is of particular value in identifying specific stressors and planning treatment to address them.     

Red Flags of Organic Recurrent Abdominal Pain in Children: Study on 100 Subjects

Objective

A variety of sign, symptoms and laboratory findings are more common in children with organic abdominal pains. This study was performed to evaluate the prevalence of organic and functional abdominal pains and relation of red flags to organic pains in 100 children with recurrent abdominal pain (RAP).

Methods

One hundred consecutive patients with RAP were enrolled in the study. A complete interview and physical examination was made for each patient, accompanied by a series of laboratory, clinical and para-clinical examinations. The data were recorded and analyzed. Logistic regression analysis was used to model and formulize correlations between sign, symptoms, and laboratory findings with organic and functional abdominal pain.

Findings

Among 100 patients (52% male, 48% female, Age: 9.29±3.17) diagnostic works up revealed organic pain for 57 patients. The most common symptoms of the patients included constipation, diarrhea, chest pain, cough, headache, vomiting, hematuria, and dysuria. Fecal incontinence, delayed puberty, organomegaly, jaundice, and family history of inflammatory bowel disease were reported in none of the patients with RAP. Fever, pain not located in periumbilical area, nocturnal pain, elevated erythrocyte sedimentation rate, weight loss, growth disorder, and abdominal tenderness were among the red flags which revealed diagnosis of organic pain in this study.

Conclusion

A series of red flags could increase likelihood of finding organic pain in children with RAP.     

Psychosomatic disorders in pediatrics

Psychosomatic symptoms are by definition clinical symptoms with no underlying organic pathology. Common symptoms seen in pediatric age group include abdominal pain, headaches, chest pain, fatigue, limb pain, back pain, worry about health and difficulty breathing. These, more frequently seen symptoms should be differentiated from somatoform or neurotic disorders seen mainly in adults. The prevalence of psychosomatic complaints in children and adolescents has been reported to be between 10 and 25%. These symptoms are theorized to be a response to stress. Potential sources of stress in children and adolescents include schoolwork, family problems, peer pressure, chronic disease or disability in parents, family moves, psychiatric disorder in parents and poor coping abilities. Characteristics that favour psychosomatic basis for symptoms include vagueness of symptoms, varying intensity, inconsistent nature and pattern of symptoms, presence of multiple symptoms at the same time, chronic course with apparent good health, delay in seeking medical care, and lack of concern on the part of the patient. A thorough medical and psychosocial history and physical examination are the most valuable aspects of diagnostic evaluation. Organic etiology for the symptoms must be ruled out. Appropriate mental health consultation should be considered for further evaluation and treatment.     

Recurrent pain,emotional distress,and health service use in childhood

OBJECTIVES: To determine the psychosocial correlates of recurrent pediatric pain and its relationship to health service use and medical presentations for "unexplained" symptoms in primary care. STUDY DESIGN: Children 4 to 15 years of age who complained frequently of aches and pains to parents were compared with those with infrequent or no pain on measures of demographics, psychopathology, school attendance and performance, perceived health, and service use. Univariate analysis was followed by logistic regression. RESULTS: Children who complained often of aches and pains used more health services, had more psychosocial problems, missed more school, and did worse academically. After controlling for health service use and demographics, recurrent pain was significantly associated with negative parental perceptions of child health and the presence of internalizing psychiatric symptoms. Higher levels of ambulatory health service use were associated with negative perceptions of child health, recurrent pain, visits for "unexplained" symptoms, and internalizing psychiatric symptoms. CONCLUSIONS: Pediatric recurrent pain challenges traditional service delivery models characterized by segregated systems of care for physical and mental disorders. Longitudinal and psychobiological studies of the relationship between recurrent pain, internalizing psychopathology, and health beliefs are warranted to direct future treatment efforts.     

Postpartum mood disorders and maternal perceptions of infant patterns in well-child follow-up visits

AIMS: The aims of this study were to evaluate the associations between postpartum depressive symptoms and maternal perceptions of infant patterns with 1-year follow-up examinations, and to assess the impacts of treatment on these perceptions. METHODS: One hundred three mother-infant pairs were evaluated. Data on maternal reports of infant feeding, sleeping and temperament patterns were collected at each well-child visit. The Edinburgh Postpartum Depression Scale was used to assess depressive symptoms. A psychiatrist interviewed the mothers with depressive symptoms, and psychiatric treatments were administered accordingly. The associations between depressive symptoms and maternal perceptions at each visit were analyzed by taking into account the entire follow-up period. RESULTS: Thirty-five mothers (34%) scored within the clinical range of the EPDS during the follow-up period. Mothers with elevated depressive symptoms were more inclined to report infant cry-fuss, sleeping and temperamental problems through the follow-up. Such complains on infant cry-fuss and temperament problems and maternal sleeping problems improved after treatment in compliant mothers. The dropout rate was high (58.3%) in noncompliant mothers. CONCLUSION: Postpartum depressive symptoms may lead to negative maternal perceptions of infant patterns. Earlier management of these disorders and maternal compliance to psychiatric suggestions may provide a better care for the mother-infant pairs.     

Maternal expressed emotion and adjustment in children with epilepsy

Epilepsy in childhood may alter family relationships but the relevance of these changes for the increased rates of psychopathology has been little investigated. This study uses maternal expressed emotion (EE) to examine family relationships of children with epilepsy and the association with high risk for psychiatric disorder. EE was assessed using the Camberwell Family Interview carried out with the mothers of 22 schoolchildren with chronic epilepsy who were attending a general hospital outpatient clinic. Sixteen of these children had similarly aged healthy siblings who served as controls. High risk for psychiatric disorder in the children and mothers was assessed using behavioural, mood, and self-esteem questionnaires completed by mothers, teachers, and children. It was found that mothers showed significantly more emotional overinvolvement and a trend for more hostility towards their children with epilepsy than towards sibling controls. For the 22 children with epilepsy, maternal emotional overinvolvement was not associated with child behavioural deviance. High levels of criticism and, to a lesser extent, hostility did show associations with child behavioural deviance, and the strongest links were between maternal criticism and maternal rated antisocial and overactive behaviour in the child. Fewer positive comments by mothers towards the children were associated with child emotional symptoms and lower self-esteem in a number of areas. This study suggests that further research could consider the appropriateness of psychological intervention for families in which mothers are critical and hostile and whose children show antisocial behaviour.     

Psychiatric manifestations of systemic lupus erythematosus in children and adolescents. A review

The purpose of this article is to review the psychiatric conditions associated with systemic lupus erythematosus (SLE) in children and adolescents. Emphasis is placed on clinical presentation and the differential diagnosis between organic psychiatric disorder, toxic psychiatric disorder, and functional psychological symptoms.     

Accuracy of Pain Recall in Children

BACKGROUND AND AIM:: Chronic abdominal pain (AP) is common in children. Recall of symptoms is used clinically to determine management, to assess treatment progress, and in drug studies to assess outcomes. Limited data exist on accuracy of AP recall in children. The aim of the present study was to assess ability to accurately recall AP in children. METHODS:: The study was a secondary analysis of data obtained from a double-blind, randomized, placebo-controlled trial, evaluating amitriptyline in children with functional gastrointestinal disorders. Children ages 8 to 17 years with AP predominant functional gastrointestinal disorders based on Rome II criteria were recruited from 6 centers. Those with evidence of organic disease were excluded. Patients maintained AP diary daily for 1 month (presence, frequency, and intensity). At the end of the study, patients reported the number of days of AP during previous month. Agreement between daily pain reports and recalled pain was assessed. Univariate analysis was conducted with Spearman rank correlations. RESULTS:: We recruited 63 children (45 girls, mean age 12.8 years). Sixteen percent children had perfect agreement on number of days of AP. Fifty-four percent of children recalled fewer episodes of pain. The average number of days with AP by recall was 17.7/month, whereas by diary it was 23.5/month (P?=?0.001). Correlation between patient recall of the last week of symptoms (r?=?0.47) was no better than correlation between recall of the last 30 days of symptoms (r?=?0.48). On comparing AP recall versus various pain intensities, reported AP did not reflect only AP of greater severity. Higher correlation of recall of symptoms was seen in children 11 years or younger (r?=?0.59) as compared with children older than 11 years (r?=?0.26). CONCLUSIONS:: Few children can accurately recall the episodes of AP. Children commonly recall a lower frequency of AP than that assessed by prospective diary reports. Reported recall does not reflect a shorter recollection period. Recall is not related to intensity of pain. Adolescents have worse recall of symptoms.     

Childhood bullies and victims and their risk of criminality in late adolescence: the Finnish From a Boy to a Man study

OBJECTIVE: To study correlations of childhood bullying and victimization with juvenile criminality. DESIGN: Longitudinal birth cohort study from age 8 years to ages 16 to 20 years. SETTING: Population-based study from Finland. PARTICIPANTS: The sample comprised 2551 boys (86.6% of the original birth cohort) with complete information about bullying and victimization from parents, teachers, and children at age 8 years. MAIN OUTCOME MEASURE: Information about criminal offenses from the National Police Register at ages 16 to 20 years. RESULTS: Frequent bullies and those who frequently both bullied and were bullied (8.8% of the sample) were responsible for 33.0% of all juvenile crimes during the 4-year study period. Frequent bully-only status predicted both occasional and repeated offending, whereas bully-victim status predicted repeated offending. Bullying predicted most types of crime (violence, property, drunk driving, and traffic offenses) when controlled with parental education level. However, frequent bullies or victims without a high level of psychiatric symptoms were not at an elevated risk for later criminality. CONCLUSIONS: Boys who frequently bully are at risk for later criminality when this condition is accompanied by a high level of psychiatric symptoms. Frequent bullies should be actively screened for psychiatric problems.     

Chronic Abdominal Pain In Children: a Technical Report of the American Academy of Pediatrics and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

Chronic abdominal pain, defined as long-lasting intermittent or constant abdominal pain, is a common pediatric problem encountered by primary care physicians, medical subspecialists and surgical specialists. Chronic abdominal pain in children is usually functional-that is, without objective evidence of an underlying organic disorder. The Subcommittee on Chronic Abdominal Pain of the American Academy of Pediatrics and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition has prepared this report based on a comprehensive, systematic review and rating of the medical literature. This report accompanies a clinical report based on the literature review and expert opinion.The subcommittee examined the diagnostic and therapeutic value of a medical and psychologic history, diagnostic tests, and pharmacological and behavioral therapy. The presence of alarm symptoms or signs (such as weight loss, gastrointestinal bleeding, persistent fever, chronic severe diarrhea and significant vomiting) is associated with a higher prevalence of organic disease. There was insufficient evidence to state that the nature of the abdominal pain or the presence of associated symptoms (such as anorexia, nausea, headache and joint pain) can discriminate between functional and organic disorders. Although children with chronic abdominal pain and their parents are more often anxious or depressed, the presence of anxiety, depression, behavior problems or recent negative life events does not distinguish between functional and organic abdominal pain. Most children who are brought to the primary care physician's office for chronic abdominal pain are unlikely to require diagnostic testing. Pediatric studies of therapeutic interventions were examined and found to be limited or inconclusive.     

A multidisciplinary approach to the management of psychosocial admissions to a general paediatric ward

This study investigated the characteristics of all new in-patients with major psychological and/or social problems admitted to a medical ward over a 4-week period. Fifteen successive patients were studied prospectively. The professional time spent by the medical and paramedical personnel involved in the initial assessment and management was reviewed, and the children followed-up 6 months later. The study found that the patients readily fell into two major groups. Group I were infants and children who had been maltreated or were at risk for child abuse. Group II were older children who presented with psychosomatic symptoms arising from disturbed family or environmental backgrounds. The medical, psychiatric and social work input was considerable for both groups (19 vs 27 h per patient respectively). Their hospital stay was prolonged (15 vs 21 days respectively; the hospital average was 4.4 days). The outcome differed in the two groups. Patients in Group I failed to attend follow-up appointments in most cases unless such attendance was legally mandatory. In contrast, Group II patients usually kept their follow-up appointments, the intervention generally being successful.     

Widespread pain and neck pain in schoolchildren. A prospective one-year follow-up study

The aims of this study were to prospectively follow up population-based cohorts of children with widespread pain, children with neck pain and pain-free children, in order to evaluate 1-y changes in pain symptoms and to evaluate predictors for persistent widespread pain and for the change of neck pain to widespread pain. A structured pain questionnaire, the Children's Depression Inventory, and a sleep questionnaire were completed by the pre-adolescent cohorts, and clinical evaluation with tender point palpation and pain threshold measurements was carried out in both years. The Child Behavior Checklist, the Teacher's Report Form and a sociodemographic questionnaire were completed at baseline. More children in the 2 pain cohorts reported pain at follow-up than did controls (p < 0.0001). Children with persistent widespread pain had lower pain thresholds compared with those whose pain classification changed. In the neck pain group, 19 (20.4%) reported widespread pain at follow-up. Although depressive symptoms and sleep problems were associated with the change of neck pain to widespread pain, neither they nor other measured factors showed independent explanatory power in multiple logistic regression analysis. In conclusion, fluctuation of pain symptoms occurred mainly among pain cohorts. Depressive and sleep problems may have an effect on the spreading of regional neck pain to widespread pain. Pain threshold measurement and evaluation of depressive and sleep problems may be useful tools for secondary prevention of musculoskeletal pain in pre-adolescents.