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Management of chronic pain is an essential part of pediatric practice that requires an understanding of pediatric illnesses and the psychosocial aspects of chronic pain conditions experienced by children. Many children experience a variety of chronic recurrent pains such as recurrent abdominal pain or headaches. Chronic recurrent pain is more common in children than persistent pain, and is less likely to be associated with underlying organic disease. Chronic pain may become persistent in conditions such as rheumatoid arthritis, malignancies, sickle cell disease, or neuropathic pain syndromes. Because of the complex nature of chronic pain, treatment is often approached from a broad-based medical model that utilizes the expertise of psychologists, neurologists, anesthesiologists, nurses, and other health care providers. This chapter reviews some of the more common types of recurrent and persistent pain among children and summarizes treatment strategies, including pharmacologic as well as nonpharmacologic therapies.

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Recurrent abdominal pain (RAP) is a common problem among school-aged children. Some studies report that as many as 25% of school-aged children will experience recurrent abdominal pain, with the highest prevalence occurring among young girls.1 Many children with RAP remain functional and maintain normal activities; patients seen at pediatric pain clinics are typically those with more severe patterns of pain and disability. In most cases, there is no clear identifiable cause of RAP in school-aged children.1,2

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There are certain clinical characteristics that distinguish benign recurrent abdominal pain (RAP) from other types of abdominal pain in children. In general, children with RAP are between the ages of 4 and 16 who experience episodic abdominal pain interspersed with pain-free periods and are otherwise thriving and medically well.2 Children with RAP frequently describe diffuse periumbilical pain that is poorly localized; it rarely radiates to the back or chest. Pain is often worse at night but rarely awakens the child from sleep. Many children will experience other chronic symptoms such as headaches, nausea, and dizziness.

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In the majority of cases, RAP is functional, which refers to the lack of an identifiable biochemical, structural, or other organic cause. The lack of a readily identifiable cause for RAP does not imply psychogenic causes. Most children with RAP are in general medically and psychologically well.3 A subgroup of patients will have a recognizable underlying disease, such as lactose intolerance, constipation, ureteropelvic junction obstruction, inflammatory bowel disease, or endometriosis.4–9 For many children, however, an underlying etiology is rarely diagnosed. Some studies have suggested that RAP may be a precursor to irritable bowel syndrome (IBS) in adults, and that some children and adolescents may progress to meet standardized criteria for IBS as adults.10-12

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The diagnosis of RAP should be based on a thorough history, physical examination, and review of symptoms. A psychosocial history is essential to learn how the child and family cope with pain and to identify school avoidance and reinforcers of pain. A history of fever, weight loss, growth failure, ...

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