Researchers seek tool for children's stomach trouble

Recurrent abdominal pain leads many young patients to the doctor's office, but ways to assess their pain and determine if treatment is working are lacking.

By Victoria Stagg Elliott — Posted Feb. 21, 2005

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The child in the office of Thomas Ball, MD, MPH, looked happy and energetic and hadn't missed a day of school. On a scale of one to 10, though, he rated his frequent attacks of stomach pain as a 10.

The next patient was glum and quiet. This child had missed his best friend's birthday party because of a stomachache. Still, he only rated the problem a 3.

"Those are extremes," said Dr. Ball, associate professor of pediatrics at the University of Arizona, Tucson. "There are all sorts of variations in between, but it is challenging."

These scenarios highlight one of the biggest difficulties physicians and researchers face when dealing with the 10% to 15% of children who complain of recurrent abdominal pain. Objective measures to assess the severity of the condition and the effectiveness of treatments are lacking but desperately needed.

"There's nothing you can measure," said Jeffrey Hyams, MD, head of the division of digestive diseases and nutrition at Connecticut Children's Medical Center in Hartford. "It's not like you can take a chest x-ray or do a blood test."

To that end, researchers at Baylor College of Medicine in Houston published a paper in the February issue of Pediatrics suggesting that questions about missed weekend activities, pain levels, nausea, loss of appetite, heartburn, diarrhea, constipation and bloating could measure the state of the disease. The multidimensional measure for recurrent abdominal pain -- MM-RAP -- was found to effectively assess children ages 4 to 18 and to work in both primary care and gastroenterology clinics.

"We're trying to see the whole picture of recurrent abdominal pain," said Hoda Malaty, MD, PhD, lead author and associate professor of medicine at Baylor. "And we want to see if the patient is getting better, because the kids might never say so."

Experts widely praised this effort for attempting to gauge something with which many physicians and patients struggle, both because of a lack of biological marker that can be checked with lab tests and the belief that many children are faking their tummy troubles.

"A tool that can be validated across different clinical settings like this one probably would be valuable if the results can be reliably reproduced," said Nader Youssef, MD, director of the Center for Pediatric Irritable Bowel and Motility Disorders at Morristown Memorial Hospital in New Jersey. "And it's very important to understand that children are not faking this kind of belly pain. There is not really a huge percentage who are getting some secondary gain from this. These kids have a worse quality of life."

Critics charged, however, that while this was a good step in the right direction, it still lacked utility. In its current form, the MM-RAP requires nearly 20 minutes to administer -- too long for the average physician visit. "I applaud the author for what she's trying to do, but this has to be shortened," Dr. Ball said.

Researchers responded that addressing this wrinkle is the most likely next step in the tool's development.

Some experts also questioned how the children were grouped together and whether 4-year-olds and 17-year-olds should be assessed in the same way. Recurrent abdominal pain is also increasingly identified by sub-types such as irritable bowel syndrome, functional dyspepsia or abdominal migraine. Experts doubted whether all children with frequent stomachaches should be lumped together.

"Recurrent abdominal pain is a descriptive term. It is not a diagnosis," Dr. Hyams said. "We're well beyond the use of the term. Lumping every body together into one wastebasket is not the right thing to do."

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Grading the impact of a child's frequent stomach pain

Objective: Develop and test the Multidimensional Measure for Recurrent Abdominal Pain -- MM-RAP -- as a potential tool to evaluate children with stomach pain.

Participants: Nearly 300 children ages 4 to 18 in physician offices or local schools who were determined to have recurrent abdominal pain.

Methods: Subjects were surveyed about socioeconomic factors, abdominal pain, other gastrointestinal symptoms and the level of disability linked to their illness.

Results: There was no significant variation in the results between younger and older children, primary care versus specialty practices, gender or parent education level. The factors assessed were strongly related but not so closely that the questions might be viewed as measuring the same thing.

Conclusion: The MM-RAP could assist physicians and researchers in evaluating young patients with recurrent abdominal pain.

Source: Pediatrics, February

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External links

"Development of a Multidimensional Measure for Recurrent Abdominal Pain in Children: Population-Based Studies in Three Settings," Pediatrics, February (link)

"Systematic Review of Treatments for Recurrent Abdominal Pain," Pediatrics, January 2003 (link)

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