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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, ...