Children With Abdominal Pain Have Poor Prognosis

Norra MacReady

May 22, 2013

Children who present to primary care with abdominal pain have a high risk of developing chronic abdominal pain (CAP) severe enough to impair their daily functioning, a new study suggests.

"Our study showed that of children complaining of abdominal pain in general practice, 78.7% had (or developed) CAP, that a considerable number fulfilled the criteria of CAP 1 year after the initial visit, and one-half of these children were still impaired in their daily functioning," lead author Yvonne Lisman-van Leeuwen, PhD, from the Department of General Practice, University of Groningen, University of Groningen Medical Center, the Netherlands, and colleagues write in an article published the May/June issue of the Annals of Family Medicine.

CAP was defined as abdominal pain that appeared at least once a month for 3 consecutive months and affected the child's daily activities or well-being.

Few data exist on the natural history of abdominal pain in children, Dr. Lisman-van Leeuwen and coauthors write. Of the studies that have been done, most were performed on children in secondary or tertiary care, who may have been more seriously ill than children seen in primary care. To examine the natural history of CAP in this population, the researchers conducted a prospective cohort study of children seen in 53 primary care practices in and around Rotterdam, the Netherlands, between May 2004 and March 2006.

Children between the ages of 4 and 17 years were eligible for inclusion if they visited the physician complaining of abdominal pain. Baseline information was obtained within 1 week of the visit, with follow-up data gathered at 3, 6, 9, and 12 months. The investigators excluded children who had visited the practitioner with a similar complaint within the 3 months before baseline or who had been diagnosed with lactose intolerance, celiac disease, or irritable bowel syndrome.

The 305 participants had a median age of 7.8 years (interquartile range [IQR], 5.7 - 10.5 years). There were 116 boys (38.0%) and 189 girls (62.0%). At the first visit, CAP was diagnosed in 142 children (46.6%) compared with 105 children (37.1%) at the 12-month follow-up visit. The most common symptom classification was functional abdominal pain in which organic disease has been ruled out, which was diagnosed in 152 children (49.8%). Irritable bowel syndrome came in second, diagnosed in 114 children (37.4%).

Although more than half of the children did not have CAP at baseline, 98 developed it at some time during the follow-up, for a total cumulative incidence of 60.1% (95% confidence interval [CI], 52.1% - 67.7%). Girls had a higher risk than boys of developing CAP, with a cumulative incidence ratio (the ratio of 2 cumulative incidence measures, which reflects the relative risk) of 1.23 (95% CI, 0.94 - 1.61). The risk also was higher among children aged 10 to 17 years than those aged 4 to 9 years (cumulative incidence ratio compared with children aged 6 to 9 years, 1.18; 95% CI, 0.86 - 1.60).

The median duration of CAP was 8.3 months (IQR, 4.5 - 12 months), with girls having a longer median duration than boys (9.0 months [IQR, 5.3 - 13.5 months] vs 7.5 months [IQR, 1.5 - 12.0 months; P = .002). Children in the 10-to-17-year age group had the longest median duration, at 9.0 months (IQR, 7.5 - 12.4 months). Irritable bowel syndrome was associated with the poorest prognosis.

"To our knowledge, no other prospective study has investigated the prevalence or incidence of CAP in children with abdominal pain in primary care," the authors write. Study limitations include the possibility that children whose pain resolved were lost to follow-up, resulting in an overestimation of pain incidence and prevalence. However, few patients actually were lost to follow-up, so the effect was probably clinically insignificant. Another limitation is the lack of information on the duration of abdominal pain before and after the study period, "so the exact duration therefore remains unknown."

The findings that so many children with abdominal pain developed CAP, and that so many remained impaired in their daily functioning, suggests a poor prognosis for CAP, the authors conclude. They recommend that these children be followed-up.

The study was funded by the Netherlands Organisation for Health Research and Development. The authors have disclosed no relevant financial relationships.

Ann Fam Med. 2013;11:238-244. Full text

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