“I have pain in my tummy again, mom”

Tummy pain and its association with stress is something we as adults have come to understand. Many experience illnesses such as irritable bowel syndrome, ulcers, reflux and so on. Today, however, we are seeing more and more children presenting at the doctor for recurrent tummy pain. It is of concern to me as a paediatrician to note the increase in the number of children missing school and having so much pain that it prevents them from enjoying normal childhood activities.

 

My intention with this blog is not to go into detail about illnesses that cause tummy pain but rather to focus on a phenomenon which I believe we as parents, caregivers and teachers have a role to play in managing “Recurrent Abdominal Pain” (RAP). I have noticed a trend in my practice which I believe ties in with RAP. Very often children who present at my practice, who are not ill but have ongoing tummy pain are very often children in Grade 4, and around the age of 9 or 10 years old. This is my own personal observation and is something I am proposing rather than claiming to be a scientific fact.

 

It is important that we understand that these are children who have three or more episodes of tummy pain in a three month period. The pain is severe and makes them unable to take part in normal activities. They are well in-between attacks, are growing normally and do not display any other sign of illness.

 

Let me start a hypothetical case as an example. This hypothetical situation is drawing on a number of cases that have I have consulted on in the past couple of years.

It was late on a Friday afternoon. I received a call from a general practitioner who wanted to refer a child to me with severe abdominal pain. He was concerned that the child may have appendicitis. The child arrived in my rooms while I was still busy with another patient. My receptionist observed that the child was very uncomfortable. While waiting the mother suggested that the child start doing some homework. Fortunately, I was ready for the child before the books were opened.

 

The mother reported that:

 

  • The child had had similar attacks over the past couple of months.
  • The pain could last up to or just longer than an hour.
  • The attacks usually subsided after a couple of days and the child continued as normal.
  • The child had missed school on occasion because of the tummy pain.
  • The family and child were anxious about the pain.
  • The child did sometimes experience nausea with the pain
  • The child was performing well at school
  • He was in the A team for soccer and cricket.
  • He did music as an additional extra-mural

 

On examination I noted that:

 

  • The child was particularly sensitive above the belly button area.
  • The child was not sensitive in the central part of the tummy and there was no pain in the right, lower part of the tummy. This is often a sign of appendicitis.
  • The tummy was soft and the child reported normal stools.
  • The tummy sounds were normal.
  • There was no fever.
  • Growth was normal for age.
  • There were no signs of trauma, genitals were normal and the child was not jaundiced.

 

At this stage I was pretty sure that the child was suffering from anxiety and this was the cause of the tummy pain. It is not an easy diagnosis to make because you have to be certain that you are not missing another cause for the ongoing pain and suggesting anxiety or depression in this age group is a sensitive issue.

The pain had completely subsided by the end of the consultation so the tests requested were not urgent.

 

I suggested that we do some basic investigations:

 

  1. An ultra-sound and x-ray of the abdomen to be sure the appendix was normal. This would also rule out constipation.
  2. A stool test to ensure that there wasn’t a bacteria or parasite in the intestines
  3. To do a urine test to exclude a urinary tract infection
  4. To do some basic blood tests.

 

By now it was 7 pm on a Friday night. All of the tests could wait until the morning, however the mother was insistent that the tests be done immediately as the child had an early morning soccer match at school. The child was captain of the A team so his team depended on him to be there. The child and mother waited in my reception area while I tried to arrange for a radiologist to come out.

While waiting for the outcome the mother also instructed the child that he had to practice the violin as soon as he got home.

 

Factors at play in this and similar situations:

 

  • An anxious child who is also a high achiever
  • A child who may not have learnt yet how to express feelings
  • Parents with high expectations
  • A school system which demands a lot from children
  • Homework which isn’t rationalised between the various teachers
  • Overloaded extra-mural timetable
  • A long and very structured day with little time for free play or relaxation.

 

Things to bear in mind:

 

  • The pain is real and fear of the pain can make it worse
  • Anxiety disorders and depression often go undiagnosed in children for a long time
  • Anxiety disorders often start in children around the age of 9 years.
  • There is a strong connection between the brain and gut. In fact they share many of the nerve connections. When a child experiences a stressful situation like a new environment, overwhelming emotions, exam stress, bullying and so on, the brain triggers the “fight or flight” response. This kind of response slows down or disrupts digestion causing abdominal pain.
  • When a child is anxious over a period of time, hormones and chemicals produced by the body land up in the digestive tract. These in tern disrupt the normal gut flora and reduce the amount of anti-bodies the gut produces. These two factors cause an imbalance in the tummy and lead to many tummy conditions which are then likely to cause pain.
  • Pain killers are not going to be a good option under these circumstances as they have side effects. Pain killers may make the gut more sensitive or may cause constipation. Both of these factors add to the tummy pain.

 

 

I have noted that a number of changes often take place at school in the grade four year ( around the age of 9 years) :

 

  • The child no longer has a single teacher so the school “mother figure” may not be as clear. This can cause separation anxiety especially for shy children.
  • The workload increases substantially in grade 4.
  • Children in our Government Schools follow the Curriculum and Assessment Policy Statements (Caps). CAPS is very similar to the IEB (Independent Education Board) so the requirements and expectations are pretty much the same.
  • CAPS sets out various standards for tests and exams. These tests and exams are usually started in the Grade 4 year.
  • Formal testing and exams increases stress in children and very often in parents as well.
  • CAPS also requires that children in Grade 4 start doing their own research. It is a great tool for encouraging critical thinking but may be difficult for children who are used to their parents being totally involved in the homework process.
  • Self-esteem and an awareness of differences in abilities also affects this age group and may leave the child feeling anxious about expectations and achievement levels.
  • Children start playing in teams which are graded. Being in the A team may mean that the child attends more practices, plays in more matches and spends longer periods of time at school.
  • Parents are often not fully aware of the dramatic difference between the junior grades and grade 4. Once parents understand these differences they will be better equipped to support their child and ease the anxiety associated with change.

 

So what are we to do about the increasing number of children suffering from abdominal pain (and other ailments) due to anxiety?

 

  • Your doctor may have to exclude medical reasons for abdominal pain.
  • Parents and teachers need to be observant of the signs and symptoms of anxiety and depression. These may include emotional outbursts, difficulty concentrating, excessive fidgeting, poor appetite and general feelings of being unwell.
  • Assist children with time management
  • Facilitate relationships between children and their teachers
  • Rationalise extra-murals. Participation in sport is far more important than being the best player in a single team.
  • Moderate exercise increases endorphins and helps to reduce stress and anxiety.
  • Deal with psychological factors that may be causing anxiety. Cognitive behaviour therapy has been shown to be highly effective.
  • Parents and family understanding how to manage the abdominal pain has been a very successful intervention.
  • Peppermint oil is a natural product which has been found to relax the intestinal muscles and helps ease the abdominal pain.
  • Mindfulness teaches the child to relax and has been shown to help relieve anxiety.
  • Teachers need to communicate with one another to spread the homework load.

 

 

Conclusion:

Tummy pain is a common problem in children under the age of 12 years and at least 2 in every 10 children will suffer from chronic tummy pain. This may be because the younger children have fewer communication skills to express how they are feeling or don’t understand it themselves.  Anxiety has increased substantially over the last decade but most children never receive care for the anxiety. Studies have shown that if anxiety in children is addressed and children are given skills to cope with anxiety, they do not go on to develop “Recurrent Abdominal Pain” syndrome.

We live in a fast and changing world but we also have tremendous knowledge and skills to teach young children how to better cope with anxiety and to find healthy ways of releasing stress before it evolves into a chronic disease. It is our responsibility as the adults to notice when a child is anxious and to seek ways to improve the situation. Being ill from the tender age of 9 years old, as a result of stress should not be a reality and we know for sure we can help children to cope better with anxiety.