Deborah Cloney, MD, Pediatric Gastroenterology
Helen DeVos Children's Hospital

After reading this article from The New York Times about abdominal complaints in children often being ignored or minimized, I felt compelled to write this blog. About 15 to 25 percent of our referrals are for chronic abdominal pain with no specific organic diagnosis and I can assure you that the pain these children experience is very real. 

We most frequently diagnose these children with functional abdominal pain; were they adults, we would likely call this irritable bowel syndrome. The children tend to be school-aged or adolescents and they have often been through a fair amount of testing by the time we see them. 

Typically, we diagnose these children with a thorough physical examination and medical history using the symptom-based Rome III criteria, for children and adolescents.

It is important, however, to be aware of any "red flags" that could signify and underlying organic pathology. These include:

Location of the pain. The pain associated with functional abdominal pain tends to be near the umbilicus or jump around; but rarely manifests continually in any other area. So if the child complains of persistent pain in the right lower quadrant, that is a clue that something else might be going on.

Persistently altered bowel habits. Children with functional abdominal pain may have occasional constipation or diarrhea, but rarely is it constant. 

Vomiting. While nausea and occasional vomiting-often induced by the pain itself-occurs with functional abdominal pain, persistent vomiting is unusual. 

Waking in the night with pain. Children may complain of pain when they go to bed, but it is very unusual for a child with functional abdominal pain to be awakened in the middle of the night because of the pain.

 Growth patterns.  Weight loss or deceleration in growth rate provides other clues that would point us away from functional abdominal pain. and in another direction.

Constitutional symptoms. Fever, night sweats, persistent gastrointestinal bleeding, or a family history of GI illnesses such as Crohn's disease also suggest an organic cause for the pain. 

It is important that you, as a physician, take complaints about persistent abdominal pain seriously. While there may be the occasional malingerer, in our experience they are rare. Minimizing the child's pain means the family will simply go elsewhere. And there are very good options you can recommend to reduce the pain, particularly behavioral modification options like hypnosis or biofeedback, relaxation therapies and/or, in some cases, low-dose tricyclic antidepressants. Don't forget to review you patient's diet, since avoiding irritant foods, such as carbonated beverages, caffeine, and greasy foods, and encouraging a high-fiber diet, can also help reduce symptoms.

It is also important to know when to stop testing, given that every test you do raises the anxiety level of the child and family once more. At some point, you need to make the diagnosis and treat for functional abdominal pain, reassuring the parents and child that the pain is very real, even though no organic cause has been identified.

Below are several review articles on diagnosing and managing functional abdominal pain in the pediatric population.

Chiou E, Nurko S. Management of functional abdominal pain and irritable bowel syndrome in children and adolescents. Expert Rev Gastroenterol Hepatol. 2010;4(3):293-304. 

Whitfield KL, Shulman RJ. Treatment options for functional gastrointestinal disorders: from empiric to complementary approaches. Pediatr Ann. 2009;38(5):288-90, 292-4.

Noe JD, Li BU. Navigating recurrent abdominal pain through clinical clues, red flags, and initial testing. Pediatr Ann. 2009;38(5):259-66. Review. 

Yacob D, Di Lorenzo C. Functional abdominal pain: all roads lead to Rome (criteria). Pediatr Ann. 2009;38(5):253-8. 

Banez GA. Chronic abdominal pain in children: what to do following the medical evaluation. Curr Opin Pediatr. 2008;20(5):571-5.

Karen Dahl, MD, Division Chief, Pediatric Infectious Disease
Helen DeVos Children's Hospital, Grand Rapids, Michigan

For the week ending January 22, 2011, Helen DeVos Children's Hospital reported six influenza A, one influenza B, three RSV, and 2 adenovirus positive tests.  Influenza activity has increased locally. The following links contain information about influenza treatment and rapid flu tests:
http://www.cdc.gov/flu/professionals/antivirals/index.htm
http://www.cdc.gov/flu/professionals/diagnosis/clinician_guidance_ridt.htm

Local bronchiolitis activity has been present for two weeks now, but likely hasn't peaked yet.

At the national level for the week ending January 15, the CDC reports that influenza activity decreased in several indicators, but it is unlikely that influenza activity for this season has peaked. Two influenza pediatric deaths were reported, and the proportion of outpatient visits for flu-like illness was 2.9%, above the national baseline of 2.5%.

Lisa M. Lowery, MD, Adolescent Medicine
Helen DeVos Children's Hospital

The December issue of Pediatrics included a clinical report from the Committee on Adolescence warning that incidence and prevalence of eating disorders among children and adolescents has "increased significantly" in recent decades, and recommending that pediatricians consider these disorders in patients with certain clinical signs. 

Although we haven't seen a similar increase in our practice (which may be related to the demographics of our patients), I have heard this from colleagues elsewhere in the country. I think it is important that clinicians be aware of the warning signs of eating disorders and not rely on outdated stereotypes that suggest such disorders are limited to upper- and middle-class white adolescent females. 

As the Pediatrics article noted, not only is there an increasing prevalence of eating disorders in males (accounting for 5-10% of all eating disorder cases), but also in minority populations and in increasingly younger children. In fact, between 1999  and 2006, hospitalizations for eating disorders in children younger than 12 jumped 119%.¹

The authors of the Pediatrics article alert also note that even if a patient doesn't meet the strict DSM-IV-TR criteria for anorexia, bulimia or other such disorders, they may still be labeled as having "partial syndromes" or "eating disorders not otherwise specified."

In our practice, we use the 5-question SCOFF Questionnaire to assess patients suspected of having an eating disorder; the Pediatrics article lists the questions. These are quick and easy questions you can ask during the visit if the patient's clinical signs raise concerns. Other questions we ask include general self-esteem questions: "How do you feel about yourself? How would you describe yourself physically?" "How much would you like the weigh?" If you have a patient who weighs 106 pounds and should weigh closer to 120 and who thinks he or she is fat, you can delve deeper.

Don't rely just on weight and height, and  BMI however; other clinical clues include hypotension, dull, thinning scalp hair; hypothermia; Russell signs (callous on knuckles from self-induced emesis), and cardiac arrhythmias. Again, the Pediatrics article provides a full list.

Are you seeing more eating disorders among your patients? Click "Add Comment" below.

Lisa M. Lowery, MD, is an adolescent medicine specialist at Helen DeVos Children's Hospital, Grand Rapids, Michigan

Reference

1. Agency for Healthcare Research and Quality. Eating disorders sending more Americans to the hospital. AHRQ News and Numbers. April 1, 2009. Available at: www.ahrq. gov/news/nn/nn040109.htm. Accessed January 13, 2011.

Karen Dahl, MD, Division Chief, Pediatric Infectious Disease
Helen DeVos Children's Hospital, Grand Rapids, Michigan

For the week ending January 15, 2011, Helen DeVos Children's Hospital reported two influenza A, two parainfluenza 3, and three RSV positive tests.  Influenza activity has been stable for the last 6 weeks. The following links contain information about influenza treatment and rapid flu tests:

http://www.cdc.gov/flu/professionals/antivirals/index.htm
http://www.cdc.gov/flu/professionals/diagnosis/clinician_guidance_ridt.htm

This may be the start of our bronchiolitis season, if activity is sustained for the next few weeks.

At the national level, the Centers for Disease Control and Prevention report that for the week ending January 8, 2011 influenza activity has decreased, but that doesn't mean that it has peaked yet for this season. Seventeen states and the District of Columbia are reporting influenza activity.

Karen Dahl, MD, Division Chief, Pediatric Infectious Disease
Helen DeVos Children's Hospital, Grand Rapids, Michigan

For the week ending January 8, 2011, Helen DeVos Children's Hospital reported one influenza A, one influenza B, and three adenovirus positive tests.  Influenza has been circulating locally for the past 5 weeks, but we are still not seeing bronchiolitis. Adenovirus has been circulating for at least 4 weeks.

At the national level, the Centers for Disease Control and Prevention reports that influenza activity has picked up over the last few weeks in the United States in a pattern typical of the start of flu season.

Kyle Morrison, Pediatric Exercise Physiologist
Healthy Weight Center
Helen DeVos Children’s Hospital

Here's the news: resistance training will not stunt a child's growth by damaging their epiphyseal plate. That comes from a major new review of resistance training in children published in the November 2010 Pediatrics.  However, the title of the review is "Effects of Resistance Training in Children and Adolescents: A Meta-analysis," not "Effects of Weight Training."

Unfortunately, when people hear the words "resistance training" they often automatically think "weight" training, as the author of a New York Times blog about the Pediatrics article certainly did. This is an important distinction that should be clarified.  While resistance training is appropriate for kids of any age, true weight training still remains appropriate only for adolescents who have completed their pubertal growth spurt.

This is clarified in the 2009 position statement from the National Strength and Conditioning Association, which holds that a "properly designed and supervised resistance training program" is relatively safe for youth, in whom it can "enhance the muscular strength and power," improve cardiovascular health, motor skill performance, and psychosocial well being, as well as increase resistance to sports-related injuries.¹

So what is a "properly designed" resistance-training program? For children ages 4 and 5, it might mean simple kinesthetic movements like hopping on one foot, playing leapfrog, lunges and jumping jacks. Older children-those who have not yet reached adolescence-might begin to learn traditional weight lifting movements, but using low-weight items, such as bench-pressing a broomstick. Other fun resistance training activities include rock climbing, gymnastics, yoga and karate.

As muscular development occurs in adolescence it is safe to begin some resistance training with bands and light weights. However, until children have finished growing and their growth plates have closed,  it is important they not participate in maximal lifting, i.e., one repetition with a weight that is as heavy as they can possibly lift. That kind of lifting is dangerous and could injure the growth plate at major joints such as the shoulder, elbow, or knees.

Unfortunately, many elite sport coaches are not aware of this and begin training kids on weights much earlier than their muscular and skeletal maturity allows. 

As pediatricians, you can provide a great benefit to your patients and their parents by educating them about the appropriate time to begin weight training-and about the difference between weight training and resistance training. It would also be advantageous to discourage parents from promoting athletic specialization in young children. Children need a variety of movement patterns. Specializing at an early age is a very risky thing to do and has been shown to reduce physical activity levels beginning in early adulthood.  

What do you think about resistance training for kids and about the trend towards early specialization in a specific sport? Click "Add Comment" below.

Kyle Morrison is a pediatric exercise physiologist at Helen DeVos Children's Hospital in Grand Rapids, Michigan.

References:

1. Faigenbaum AD, Kraemer WJ, Blimkie CJR, et al. Youth Resistance Training: Updated Position Statement Paper from the National Strength and Conditioning Association. J Strength Condit Res. 2009;23(5 suppl):S60-79.