DOI: 10.1542/pir.

31-5-e36
2010;31;e36 Pediatrics in Review
David Gottsegen
Complementary, Holistic, and Integrative Medicine: Recurrent Abdominal Pain
http://pedsinreview.aappublications.org/content/31/5/e36
located on the World Wide Web at:
The online version of this article, along with updated information and services, is
Pediatrics. All rights reserved. Print ISSN: 0191-9601.
Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2010 by the American Academy of
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
publication, it has been published continuously since 1979. Pediatrics in Review is owned,
Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly
at Indonesia:AAP Sponsored on October 23, 2013 http://pedsinreview.aappublications.org/ Downloaded from at Indonesia:AAP Sponsored on October 23, 2013 http://pedsinreview.aappublications.org/ Downloaded from at Indonesia:AAP Sponsored on October 23, 2013 http://pedsinreview.aappublications.org/ Downloaded from at Indonesia:AAP Sponsored on October 23, 2013 http://pedsinreview.aappublications.org/ Downloaded from at Indonesia:AAP Sponsored on October 23, 2013 http://pedsinreview.aappublications.org/ Downloaded from
DOI: 10.1542/pir.31-5-e36
2010;31;e36 Pediatrics in Review
David Gottsegen
Complementary, Holistic, and Integrative Medicine: Recurrent Abdominal Pain
Services
Updated Information &
http://pedsinreview.aappublications.org/content/31/5/e36
including high resolution figures, can be found at:
References
http://pedsinreview.aappublications.org/content/31/5/e36#BIBL
This article cites 26 articles, 6 of which you can access for free at:
Subspecialty Collections
gy_sub
http://pedsinreview.aappublications.org/cgi/collection/gastroenterolo
Gastroenterology
y_-_integrative_medicine_sub
http://pedsinreview.aappublications.org/cgi/collection/complementar
Complementary & Integrative Medicine
following collection(s):
This article, along with others on similar topics, appears in the
Permissions & Licensing
http://pedsinreview.aappublications.org/site/misc/Permissions.xhtml
in its entirety can be found online at:
Information about reproducing this article in parts (figures, tables) or
Reprints
http://pedsinreview.aappublications.org/site/misc/reprints.xhtml
Information about ordering reprints can be found online:
at Indonesia:AAP Sponsored on October 23, 2013 http://pedsinreview.aappublications.org/ Downloaded from
Complementary, Holistic, and Integrative
Medicine: Recurrent Abdominal Pain
David Gottsegen, MD*
Author Disclosure
Dr Gottsegen has
disclosed no nancial
relationships relevant
to this article. This
commentary does not
contain a discussion
of an unapproved/
investigative use of a
commercial product/
device.
Introduction
Recurrent or chronic abdominal pain is a common and often perplexing condition,
affecting between 15% and 35% of the pediatric population worldwide. Apley (1) rst
dened recurrent abdominal pain (RAP) in 1958 as at least three episodes of abdominal
pain sufcient to disrupt a childs daily activities over the previous 3 months.
At the time of Apleys study, only 5% of cases were found to have an organic cause. With
newer diagnostic methods, up to one third of cases of RAP may be found to have organic
causes. Red ags that might indicate specic organic diseases are: a family history of
inammatory bowel disease, fever, weight loss, night awakening, anemia, bloody stools,
and localized tenderness.
Most children who do not have specic organic disorders have functional RAP. The
causes of functional abdominal pain still are poorly understood but are believed to be due
to autonomic dysfunction or visceral hypersensitivity to stimuli such as intestinal bowel
gas, an acute trigger such as a viral gastroenteritis, an increased central perception of pain,
and altered bowel habits such as constipation. Perception of pain is mediated by temper-
amental, cultural, and psychological factors, such as anxiety or depression, and social
stressors, such as learning difculties and family stress.
Functional abdominal pain may be categorized into four specic disorders, as described
by the Rome III criteria for functional gastrointestinal (GI) disorders: functional dyspep-
sia, functional abdominal pain, irritable bowel syndrome (IBS), and abdominal migraine.
Postprandial abdominal pain, with feelings of bloating, gas, or heartburn, is classied as
dyspepsia and may be associated with gastroesophageal reux. IBS is characterized by
cramping pain with alteration in bowel movements. Episodic abdominal pain associated
with headache and pallor may be an abdominal migraine.
As with other illnesses, especially chronic conditions such as RAP, patients and families
increasingly are turning to complementary and alternative medicine (CAM). In a group of
749 children visiting pediatric gastroenterology clinics in the Netherlands, 60%were found
to have used CAMtherapies. (2) Lack of effectiveness and incidence of adverse effects with
standard medical therapy, along with school absenteeism, were the major reasons given for
the use of such therapies. This article reviews the evidence-based CAM treatments for
recurrent functional abdominal pain in children.
Biobehavioral Methods
Not surprisingly for a condition that involves the mind-body connection to such an extent,
biobehavioral methods are the most effective evidence-based treatments for functional
abdominal pain. It is important that families and children are educated about the
importance of the mind-body connection. Parents and caregivers should be reassured that
the pain is real, but it should be reframed in the context of a heightened sensitivity to
normal stomach and bowel functions. Parents should not question children about their
pain and should give them extra attention for nonpain behavior. It is important not to
undertake unnecessary laboratory tests, procedures, and surgery. It is vital that children be
taught to continue school and other normal activities, even before they are cured.
In 2003, Weydert and associates (3) systematically reviewed 57 studies of children who
had functional abdominal pain and found that psychological interventions such as cogni-
tive behavioral therapy (CBT) and hypnosis had the greatest efcacy. Since then, others
*Department of Pediatrics, Tufts University School of Medicine, Baystate Medical Center, Springeld, Mass.
NOTE: The agents discussed in this series are designated as dietary supplements rather than drugs. Although dietary
supplements are regulated by the United States Food and Drug Administration (FDA), their manufacturers may make claims
with little evidence and need not prove safety prior to marketing. The burden is on the FDA to monitor safety after the
product is on the market. Readers are referred to the 1994 Dietary Supplement Health and Education Act (www.cfsan.fda.gov/
dms/dietsupp.html).
Article complementary medicine
e36 Pediatrics in Review Vol.31 No.5 May 2010
have found that although few good controlled trials have
been performed, the best evidence supports behavioral
treatment. (4)(5)(6)
A number of randomized, controlled studies have
shown the effectiveness of CBT for RAP. In these stud-
ies, children and caregivers were taught to reframe the
perception of pain; establish contingency plans for man-
agement of pain; reward well behavior and ignore pain
behavior; and use positive self-talk, relaxation, and imag-
ination skills.
Sanders and colleagues (7) found that 56% of children
who received CBT were pain-free according to a pain
diary, and 70% were pain-free 6 months after interven-
tion, based on parental observation. By comparison, only
24% and 38%, respectively, were pain-free in the control
group. Humphreys and Gevirtz (8) found that in groups
of children taught biofeedback or CBT, 72% were pain-
free after intervention. Robins and coworkers (9) found a
decrease of 25% in abdominal pain index scores immedi-
ately and 6 and 12 months after intervention with CBT
and a 30% decrease in school absences compared with
controls. Duarte and associates (10) found that the me-
dian number of pain episodes per month decreased from
15 to 2 in the CBT group after the fourth monthly
session and decreased from 12 to 8 in the control group
in the same period of time.
Hypnosis and biofeedback have been found to be very
effective for the amelioration of suffering and pain in
headaches and a variety of chronic pain syndromes. Hyp-
nosis has been found to alter functional magnetic reso-
nance imaging signal densities in the anterior cingulate
gyrus and other regions of the brain, where abdominal
pain is perceived and modulated. Hypnotherapy includes
many of the same principles and techniques used in CBT:
an explanation of the physiology of pain, an emphasis on
nonpain behavior (favorite activities), relaxation, and
mental imagery. However, hypnosis also includes specic
suggestions for the relief of pain and continuation of
normal activities.
Ball and associates (11) taught relaxation mental im-
agery techniques to a small group of children, who
experienced a 67% overall decrease in dyspepsia-like pain,
as measured by the Faces scale. Others adapted the
gut-directed hypnotherapy developed in England (12)
and in North Carolina (13) for adults who had IBS.
Vlieger and colleagues (14) found that developmentally
appropriate gut-directed hypnotherapy, used in six 50-
minute sessions with children ages 8 to 18 years, resulted
in 85% remission of symptoms at 1 year compared with
25% remission in symptoms for those in a control group
receiving standard medical therapy.
In an intriguing recent study, van Tilburg and co-
workers (15) employed home-based guided imagery re-
cordings regularly in a group of children ages 6 to 15
years who had functional abdominal pain. A total of 63%
in the treatment group responded favorably to this ther-
apy compared with only 27% in a control group receiving
medicine only. When the control group practiced home-
based guided imagery, 62% were treatment responders.
Biofeedback combines relaxation and mental imagery
with visual or auditory feedback of somatic changes (skin
temperature, skin resistance, or heart rate variability).
Biofeedback may be especially useful in modulating the
autonomic reactivity found in many patients experienc-
ing functional abdominal pain, as measured by rectal
manometry. Humphreys and Gevirtz (8) used simple
thermal regulation techniques, in which patients are
taught to alter the skin temperature in their ngertips.
Diet and Natural Health Products
Interventions involving dietary manipulations, including
increased ber, lactose elimination, and supplements
such as peppermint oil, have met with variable success.
Although lactose intolerance is common among
adults of specic ethnic groups and nationalities, it is
fairly rare among children. In a 1981 study, researchers
found that a lactose-free diet did not result in signicant
change in abdominal pain symptoms, even among chil-
dren who were shown to be lactose-intolerant on breath
hydrogen testing. (16)
In 2001, Kline and associates (17) published their
ndings of a randomized, controlled study of 50 children
who had RAP. The children in the treatment group
received one to two enteric-coated capsules containing
187 mg of peppermint oil three times a day for 2 weeks.
Results showed that 76% of treated children had a de-
crease in severity of symptoms compared with 19% re-
ceiving a placebo. Enteric-coated peppermint is believed
to inhibit smooth muscle contractions in the gut. It also
has a mild topical anesthetic effect.
The salutary effects of dietary ber on the gut are well
known. The highly rened and processed foods that
make up much of the American diet contribute to the
increase in constipation and obesity in American chil-
dren. Caffeine, fatty or spicy foods, or carbonated bever-
ages may trigger abdominal pain. However, the thera-
peutic effect of increased ber alone on amelioration of
pain symptoms is questionable.
Feldman and colleagues (18) reported a 50% reduc-
tion in abdominal pain among children receiving 10 g of
insoluble ber in cookie form compared with a 27%
reduction in the placebo group. However, these results
complementary medicine recurrent abdominal pain
Pediatrics in Review Vol.31 No.5 May 2010 e37
did not achieve statistical signicance. In a similar con-
trolled study that used larger amounts of ber, Chris-
tensen (19) found no difference between treatment and
control groups. Humphreys and Gevirtz (8) used a
group that received ber supplementation as a control in
comparison with their active intervention groups who
received behavioral treatments. Only 7% of children who
received ber alone were pain-free after treatment.
Because patients who have IBS, which encompasses a
large percentage of children who experience RAP, have
been shown to have decreased heterogeneity of their
fecal ora compared with healthy individuals, probiotics
such as Lactobacillus and Bidobacteriumhave been used
to alter the ecosystem of the gut therapeutically. These
bacteria help to maintain a healthy intestinal mucosal
barrier and prevent bacterial overgrowth. Probiotics also
may decrease visceral hypersensitivity through an anti-
inammatory effect. Probiotics have been found to be
useful in adults who have travelers diarrhea and children
who have acute gastroenteritis. Whorwell and associates
(20) found that the probiotic Bidobacterium infantis
35624, administered in encapsulated form, in a specic
dose of 110
8
colony-forming units, signicantly re-
duced symptoms in a large group of adult patients who
had IBS.
The effectiveness of probiotics in the treatment of
RAP in children is mixed. Bausserman and Michail, (21)
in a randomized, controlled study, found no difference in
severity of pain or symptoms of bowel irregularity in a
group of children receiving a Lactobacillus GG capsule
compared with a placebo group, although the treatment
group did have slightly reduced feelings of abdominal
distention.
A smaller observational study involving children who
had abdominal pain caused by constipation and were
given a capsule containing Lactobacillus and Bidobacte-
rium found an increase of bowel movement frequency
from2 each week to 4.2 each week and a 50% decrease in
pain. (22) However, these children also had encopresis
and received enemas for 3 days as part of their treatment.
Gawronska and coworkers (23) reported no overall dif-
ferences in improvement of pain between placebo and
Lactobacillus treatment groups in a study of 48 children,
although 25% in the treatment group reported no pain
at the end of the study, compared with 10% in the
placebo control group.
Part of the reason for the mixed results of the effec-
tiveness of probiotics in the literature may be the rela-
tionship of effectiveness with the specic strain of bacte-
ria, the precise dose, and the vehicle that delivers the
probiotic. Whorwells group found that the Bidobacte-
rium administered at either smaller (110
6
) or larger
(110
10
) doses than the therapeutic dose (110
8
) were
no more effective than placebo. (20)
Seventy-ve studies of Chinese herbs or Ayurvedic
remedies for IBS in adults are reported in the literature,
three of which are double-blind randomized, controlled
trials, (24) but no studies report the use of these herbs in
children who have RAP. Some studies show the efcacy
of chamomile and fennel in infants who demonstrate
symptoms of colic. These herbs, along with ginger, have
long been used to help with GI disorders in many cul-
tures.
One observational study (25) compared a homeo-
pathic remedy, spascupreel, to the antispasmodic hyo-
scine butyl bromide, a medication commonly used to
treat functional abdominal pain. Both medications had
similar effects on scores of a symptom scale.
Physical Methods
Six randomized, controlled trials have shown variable
results for acupuncture as a treatment for IBS in adults,
(26) but the literature contains no studies of acupuncture
or any other physical treatment on children who have
RAP.
References
1. Apley J. A common denominator in the recurrent pains of
childhood. Proc R Soc Med. 1958;51:10231024
2. Vlieger AM, Blink M, Tromp E, Benninga MA. Use of comple-
mentary and alternative medicine by pediatric patients with func-
tional and organic gastrointestinal diseases: results from a multi-
center survey. Pediatrics. 2008;122:e446e451
3. Weydert JA, Ball TM, Davis MF. Systematic review of treat-
ments for recurrent abdominal pain. Pediatrics. 2003;111:e1e11
4. Perez ME, Youssef NN. Dyspepsia in childhood and adoles-
cence: insights and treatment considerations. Curr Gastroenterol
Rep. 2007;9:447455
5. Brent M, Lobato D, LeLeiko N. Psychological treatments for
pediatric functional gastrointestinal disorders. J Pediatr Gastroen-
terol Nutr. 2009;48:1321
6. Huertas-Ceballos A, Logan S, Bennett C, Macarthur C. Psycho-
social interventions for recurrent abdominal pain (RAP) and irrita-
ble bowel syndrome (IBS) in childhood. Cochrane Database Syst
Rev. 2008;1:CD003014
7. Sanders MR, Shepherd RW, Cleghorn G, Woolford H. The
treatment of recurrent abdominal pain in children: a controlled
comparison of cognitive-behavioral family intervention and stan-
dard pediatric care. J Consult Clin Psychol. 1994;62:306314
8. Humphreys PA, Gevirtz RN. Treatment of recurrent abdominal
pain: components analysis of four treatment protocols. J Pediatr
Gastroenterol Nutr. 2000;31:4751
9. Robins PM, Smith SM, Glutting JJ, Bishop CT. A randomized
controlled trial of a cognitive-behavioral family intervention for
pediatric recurrent abdominal pain. J Pediatr Psychol. 2005;30:
397408
complementary medicine recurrent abdominal pain
e38 Pediatrics in Review Vol.31 No.5 May 2010
10. Duarte MA, Penna FJ, Andrade EM, Cancela CS, Neto JC,
Barbosa TF. Treatment of nonorganic recurrent abdominal pain:
cognitive-behavioral family intervention. J Pediatr Gastroenterol
Nutr. 2006;43:5964
11. Ball TM, Shapiro DE, MonheimCJ, Weydert JA. A pilot study
of the use of guided imagery for the treatment of recurrent abdom-
inal pain in children. Clin Pediatr. 2003;42:527532
12. Whorwell PJ, Prior A, Faragher EB. Controlled trial of hypno-
therapy in the treatment of severe refractory irritable-bowel syn-
drome. Lancet. 1984;2:12321234
13. Palsson OS. Standardized hypnosis treatment for irritable
bowel syndrome: the North Carolina protocol. Int J Clin Exp Hypn.
2006;54:5164
14. Vlieger AM, Menko-Frankenhuis C, Wolfkamp SC, Tromp E,
Benninga MA. Hypnotherapy for children with functional abdom-
inal pain or irritable bowel syndrome: a randomized controlled trial.
Gastroenterology. 2007;133:14301436
15. van Tilburg MA, Chitkara DK, Palsson OS, et al. Audio-
recorded guided imagery treatment reduces functional abdominal
pain in children: a pilot study. Pediatrics. 2009;124:e890e897
16. Lebenthal E, Rossi TM, Nord KS, Branski D. Recurrent ab-
dominal pain and lactose absorption in children. Pediatrics. 1981;
67:828832
17. Kline RM, Kline JJ, Di Palma J, Barbero GJ. Enteric-coated,
pH-dependent peppermint oil capsules for the treatment of irritable
bowel syndrome in children. J Pediatr. 2001;138:125128
18. Feldman W, McGrath P, Hodgson C, Ritter H, Shipman RT.
The use of dietary ber in the management of simple, childhood,
idiopathic, recurrent, abdominal pain: results in a prospective,
double-blind, randomized, controlled trial. Am J Dis Child. 1985;
139:12161218
19. Christensen MF. Recurrent abdominal pain and dietary ber.
Am J Dis Child. 1986;140:738739
20. Whorwell PJ, Altringer L, Morel J, et al. Efcacy of an encap-
sulated probiotic Bidobacterium infantis 35624 in women with
irritable bowel syndrome. Am J Gastroenterol. 2006;101:
15811590
21. Bausserman M, Michail S. The use of Lactobacillus GG in
irritable bowel syndrome in children: a double-blind randomized
control trial. J Pediatr. 2005;147:197201
22. Bekkali NL, Bongers ME, van den Berg MM, Liem O, Ben-
ninga MA. The role of a probiotics mixture in the treatment of
childhood constipation: a pilot study. Nutr J. 2007;6:17
23. Gawronska A, Dziechciarz P, Horvath A, Szajewska H. A ran-
domized double-blind placebo-controlled trial of Lactobacillus GG
for abdominal pain disorders in children. Aliment Pharmacol Ther.
2007;25:177184
24. Liu J, Yang M, Liu Y, Wei M, Grimsgaard S. Herbal medicines
for treatment of irritable bowel syndrome. Cochrane Database Syst
Rev. 2009;1:CD004116
25. Muller-Krampe B, OberbaumM, Klein P, Weiser M. Effects of
spascupreel versus hyoscine butyl bromide for gastrointestinal
cramps in children. Pediatr Int. 2007;49:328334
26. Lim B, Manheimer E, Lao L, et al. Acupuncture for treatment
of irritable bowel syndrome. Cochrane Database Syst Rev. 2009;4:
CD005111
Summary
A comprehensive review of the scientic literature
reveals little evidence for the effectiveness of any
specic herbal or nutritional product or the use of
supplemental ber for the treatment of RAP.
Although not the subject of this article, it should be
mentioned that no evidence exists for the efcacy of
any pharmaceutical product for RAP either, other
than famotidine for treating dyspepsia (one small
randomized, controlled trial) and pizotifen for the
small subclass of children who suffer abdominal
migraines (a smaller randomized, controlled trial).
There is no evidence in the literature for the
effectiveness of any physical manipulations or
methods in treating RAP in children.
Evidence is growing that supports the use of
biobehavioral methods for the treatment of RAP. The
most validated techniques are CBT and
hypnotherapy, which is not surprising because RAP
usually is functional. Functional refers to the cause
not being organic, but rather due to a complex
process that includes mind and body such as central
sensitivity to pain, visceral hypersensitivity,
autonomic dysfunction, and other factors still to be
discovered. Mind-body or behavioral techniques help
children return to normal daily activities, reinterpret
their pain to lessen their suffering, and improve
feelings of efcacy and self-worth. Specically,
guided imagery and hypnosis have been found to be
highly effective in the treatment of nonorganic
abdominal pain in children.
Much more research, perhaps combining
biobehavioral techniques with other traditional and
complementary/integrative methods, needs to be
conducted for this common and often perplexing
pediatric disorder.
complementary medicine recurrent abdominal pain
Pediatrics in Review Vol.31 No.5 May 2010 e39