Introduction Epidemiology Recurrent abdominal pain has long been acknowledged to be one of the most common chronic pain entities in children. However, only recently has it been recog nized as a global health problem. Th e prevalence has been estimated at 0.3% to 19% (median 8.4) in Western populations (Chitkara et al., 2005 ), with similar rates recently document ed worldwide and including developing countries (Devanarayana et al., 2011 ; Zhou et al., 2 011 ). Prevalence appears to peak in early school-age (4 \200\2236 years) and preadolescent children, with females somewhat overrepresented at older ages (Chitkara et al., 2005 ). Ab dominal pain can persist for years with many chil- dren continuing to have problems with bo th abdominal pain and associated symptoms into adulthood (Gieteling et al., 2008 ). History In the late 1950s, Apley and Naish fi rst described the entity which became known a s recurrent abdominal pain of childhood or \200\230RAP \200\231 (Apley and Naish, 1958 ). RAP was described as three or more bouts of pain severe enough to aff ect activities that o ccurred over a period of at least 3 months. Less than 10% of the patients evaluated by Aple y and Naish were determined to have an organic etiology for their pain. Given the lack of d iagnostics available during that time, it is likely that some children with organic disease were included under this heading. Even more important, children with a wide variety of cli nical presentations and aetiologies were lumped under the single clinical \200\230diagnosi s \200\231 of RAP. RAP was so inclusive as to be Etiology FGIDs are probably best understood utilizing a biopsychosocial model which states that abdominal pain occurs as a result of vary- ing contributions from, and interactions be tween, biological factors, psychological factors, and social factors. Each of these factors may initiate or contribute to the frequency, duration, or intensity of pain. Further, this model is dynamic; children are believed to achieve the same end result (i.e. abdominal pai n) through diff erent pathways. SECTION 4 pain in specific populations and diseases 290 Biological factors Th e biological factors most implicated in the generation of abdom- inal pain include motility disturbances, visceral hypersensitivity, and infl ammation. A variet y of motility disturbances have been well documented in adults with both IBS and FD. Althou gh there are many fewer pediatric studies, the fi ndings in children tend to parallel those in adults. IBS is associated with either rapid colonic transit typical of diarrhea-predomi nant IBS (D-IBS) or delayed colonic transit typical of constipation-predominant IBS (C-IBS) . However, transit is increased in only 48% of adults with D-IBS and decreased in only 20% of those with C-IBS (Camilleri and Di Lorenzo, 2012 ). FD has been associated with a wide a rray of electromechanical disturbances in adults including delayed gastric emptying, gastri c electrical disturbances, impaired fundic accom- modation (relaxation) with meals, and dis coordinated gastroduo- denal motility (Timmons et al., 2004 ). Delayed gastric emptying and gastric electrical disturbances have each been demonstrated in approximately 50% of childr en with FD (Friesen et al., 2006 ). Symptom severity also has been correlated with delayed empty- ing, gastric electrical abnormalities, impaired antral motility, and impaired accomm odation in children with FD (Friesen et al., 2006 ; Devanarayana et al., 2008 , 2012 ; Olaf sdottir et al., 2000 ). Box 29.1 Rome III symptom criteria for functional gastrointestinal disorders related to abd ominal pain in children Functional dyspepsia All of the following present at least once weekly for at least 2 months: \227\206 Persistent or recurrent abdominal pain or discomfort centered in the upper abdomen. \227\206 Pain not relieved by defecation or associated with a change in stool frequency or form. \227\206 No evidence of an infl ammatory, anatomic, metabolic, or neo- plastic process to explain the symptoms. Irritable bowel syndrome All of the following present at least once weekly for at least 2 months: \227\206 Abdominal discomfort or pain associated with two or more of the following: \227\206 improvement with defecation \227\206 onset associated with a change in stool frequency Visceral hypersensitivity is believed to be of central importance in the generation of pain in FGIDs in adults with similar, but some- what confl icting, studies in children. In adul ts with IBS, increased rectal sensitivity to stretch has been reported in 21% to 95% of pat ients (Camilleri and Di Lorenzo, 2012 ). Rectal hypersensitivity has been demonstrated to h ave a sensitivity of 89% and a specifi city of 83% in identifying children with IBS (Camill eri and Di Lorenzo, 2012 ). However, other studies have demonstrated much lower rates of hy persensitivity with no diff erences between pediatric patients with IBS and FAP. In adults with FD, visceral hypersensitivity to dis- tension has been demonstrated in 34% to 65% of p atients (Timmons et al., 2004 ). Hypersensitivity to acid has also been reported in adults with FD (Oshima et al., 2012 ). Water load volume, an indicator of visceral sensitivity, ha s been shown to diff er between children with abdominal pain (including those specifi cally with FD) and controls (Anderson et al., 2008 ; Schurman et al., 2007 ). \227\206 onset associated with a change in stool form. \227\206 No evidence of an infl ammatory, anatomic, metabolic, or neo- plastic process to explain the symptoms. Functional abdominal pain All of the following present at least once weekly for at least 2 months: \227\206 Episodic or continuous abdominal pain. \227\206 Does not meet criteria for another FGID. \227\206 No evidence of an infl ammatory, anatomic, metabolic, or neo- plastic process to explain the symptoms. Abdominal migraine Th e two main infl ammatory cells which have been implicated in FGIDs are mast cells and eo sinophils. In adults with IBS, mast cells are increased in the ileum and colon, are more li kely to be in close proximity to nerves, and are more likely to be activated when near nerv es; in addition, when near nerves, their density correlates with pain severity (Barbara et al., 2006 ; Park et al., 2003 ; Santos et al., 2005 ). Treatment with mast cell stabilizers has been shown to decrease the visceral hypersensitivity in IBS patients (Klooker et al., 2010 ). Mast cell density has been shown to be increased in the stomach of adults with FD a nd their activation is associated with visceral hypersensitivity (Hall et al., 2003 ; Hou e t al., 2001 ). Duodenal eosinophils also have been highly implicated, with den- sity signif i cantly increased in adults with FD (Walker et al., 2011 ). Treatment directed at mucosal eosinophils has been shown to decrease pain in children with FD in association with duodena l eosinophilia (Friesen et al., 2004 ). All of the following must have occurred at least twice in the pre- ceding 12 months: \227\206 Paroxysmal episodes of intense, acute periumbilical pain last- ing at least 1 h. \227\206 Intervening periods without pain lasting weeks to months. \227\206 Pain which interferes with normal activities. \227\206 Pain associated with at least two of the following: \227\206 anorexia \227\206 nausea \227\206 vomiting \227\206 headache \227\206 photophobia \227\206 pallor. Stress response and biological factors Stress in various forms predisposes adults to develo p IBS and increases symptoms in children with FGIDs (Katiraei and Bultron, 2011 ; Walker et al., 2011 ). Anxiety and stress appear to interact \227\206 No evidence of an infl ammatory, anatomic, metabolic, or neo- plastic process to explain the symptoms. Reproduced with kind permission of the Rome Foundation, Copyright Rome Foundation, Inc. CHAPTER 29 recurrent abdominal pain 291 with the gastrointestinal tract primarily through release of corti- cotrophin-releasing hor mone (CRH) with secondary activation of mucosal mast cells. CRH mediates visceral sensitivi ty by activating mucosal mast cells with subsequent mediator sensitization of aff er- ent s ensory enteric nerves (Wood, 2004 ). An association has been reported between elevated rect al mast cells and anxiety in adults with IBS (Dunlop et al., 2002 ). Adults have demonstrat ed selec- tive luminal release of tryptase and histamine from jejunal mast cells under cold stress; the magnitude of release was similar to that induced by allergen exposure in food allergic patients (Santos et al., 1998 ). Th e gastrointestinal response to stress can be m itigated by mast cell-stabilizing drugs (Moeser et al., 2007 ). An association between antr al mast cell density and anxiety also has been demon- strated in children with FD (Schurman et al., 2010 b). School can be very stressful for children with learning or social problems, particularly if these are not identifi ed and treated eff ec- tively; escape from school may be very reinf orcing for these chil- dren. One study found an inverse relationship between academic abili ty and number of visits to the school health offi ce for physi- cal complaints, including \200\230stomach ache, \200\231 such that regular educa- tion students with lower academic a bility were 4.25 times more likely to visit the health offi ce at school than students with high academic ability (Shannon et al., 2010 ). Similarly, in children with IBS, a stronger relationship between symptoms and disability has been documented for girls with lower perc eived social competence and for boys with lower perceived athletic competence (Claar et al. , 1999 ). More broadly, life event stress has been found to be higher in children with FGID s, and the relationship between daily stressors and physical complaints is stronger, than i n healthy control peers (Di Lorenzo et al., 2005 b). Psychological factors Children with FGIDs tend to have more concurrent symptoms of anxiety and depression than their peers (Di Lorenzo et al., 2005 b). Further, early temperament mar kers of anxiety may predict a rela- tive increased risk for the development of FGIDs in ear ly school-age, while children with FGIDs appear to be at increased risk for anxiety and dep ression in the future (Di Lorenzo et al., 2005 b; Ramchandani et al., 2006 ). While externa lizing issues (e.g. aggression, conduct problems) may present in a subset of children with FGIDs, they are certainly far less common (Schurman et al., 2008 ). To date, however, there is no evidence that emotional or behavioral symptoms pre- dict symptom severity, course, o r response to treatment. Even areas of diffi culty that are clearly consequences of pain, aris- ing secondary to pai n onset, are important to consider in evalu- ation and treatment, as they may ultimately pl ay a contributory role in pain maintenance and/or escalation. Functional disability is one such area. Children with frequent abdominal pain are at increased risk for social isolation and school absenteeism (Youssef et al., 2008 ). Children with FGIDs report quality of life lower than healthy peers and similar to that of children with infl ammatory bowel disease (Youssef et al., 2006 ). However, recent research has highlighted the reciprocal nature of the relationship between pain and disability. While pain and disability are associated cros s-sec- tionally, cutting back in normal daily activities on the current day appears to incr ease the subjective experience of pain and the likeli- hood of further activity cutbacks on the subsequent day (Schurman et al., 2011 ). Ultimately, over time, this may lead to an es calating cycle of pain and disability. Social factors While it is natural for parents to want to comfort their children when in pa in, solicitous parenting behaviors have been found to predict prolonged illness, symptom re occurrence, and increased disability in children with chronic medical conditions, including FGIDs (Brace et al., 2000 ; Walker and Zeman, 1992 ). Parental attention to the child \200 \231s abdominal pain has been shown to increase verbal complaints in response to a water lo ad task as compared to parental distraction; these behavioral changes were found despite ch ildren reporting sim- ilar levels of experienced pain across conditions (Walker et al., 200 6 ). Parents of patients with FGIDs also tend to have more symptoms of anxiety and depressi on, as well as more physical complaints, leading to speculation that these parents may mode l more illness behavior for their child, provide more attention to their child \200\231s ph ysical symp- toms, and/or bestow on the child a predisposition toward anxiety and/or gastro intestinal dysfunction (Ramchandani et al., 2006 ). Implications for care Evaluation To date, no evidence-based guidelines exist for the evalua tion of chronic abdominal pain, in general, or for any specifi c FGID related to pain in ch ildren. Currently, the presence of alarm signs and symptoms are accepted as indicators of p otential organic dis- ease and indications for further evaluations ( Table 29.1 ). In the p resence of alarm symptoms, blood tests, radiological evaluation, and endoscopy are reasonab le evaluations and some recommenda- tions are included in Table 29.1 . In the absence of al arm symptoms, it is reasonable to make a diagnosis of a FGID without performing testing ini tially. In general, there is insuffi cient literature regarding the utility of any specifi c diagnostic tests in children with chronic abdominal pain including blood tests, ultrasoun d, or endoscopy (Di Lorenzo et al., 2005 b). Despite the lack of studies, blood tests and e ndoscopy remain the most commonly performed \200\230standard \200\231 tests in the evaluat ion of dyspepsia in children in pediatric gas- troenterologist practice (Schurman et al., 2 010 a). Ultimately, most children with chronic abdominal pain probably will not have an ide ntifi ed specifi c disease accounting for their symptoms. However, as discussed in the cont ext of the biopsychosocial model, this does not mean that there are not biological contribu tors to the patient \200\231s pain. In fact, it is likely that there are biological contrib utors in the majority of cases and that, even in patients where symptoms are driven primari ly by anxiety or stress (if we had a means to make Other factors While impractical to list all possible potential contributors to an individua l child \200\231s abdominal pain experience, several additional areas merit specifi c menti on. Sleep can play a major contribut- ing role in the maintenance of chronic pain. Pain oft en results in increased stress and arousal that can interfere with the quality and quantit y of a child \200\231s sleep, while decreased sleep quality and quan- tity have been found to predict increased pain the following day (Lewin and Dahl, 1999 ). Disrupted sleep has be en found to result in increased emotional/behavioral problems that can, in turn, lower a ch ild \200\231s pain tolerance, interfere with eff ective use of coping skills, and increase functional disability (Kundermann et al., 2004 ). Finally, adequate sleep appears to promot e tissue healing, immune function, and the body \200\231s natural analgesic eff orts, which can aid in both pain relief and recovery (Lewin and Dahl, 1999 ). SECTION 4 pain in specific populations and diseases 292 Table 29.1 Alarm signs and symptoms for chronic or recurrent abdominal pain with suggested initial workup simultaneously as many of the identifi ed biopsychosocial contribu- tors as possible, with the belief that this provides the best opportu- nity to eff ectively break the pain cycle. In addition, the importance of early intervention cannot be overstated given the potential long- term consequences of functional disability on academic, social, and emotional develop ment in children and adolescents. Th e following presents a stepped approach to care, begin ning with what may be realistically accomplished within the primary care offi ce setting, m oving through referral for subspecialty collaboration, and ending with more intensive rehab ilitation models for treatment. Signs/symptoms Initial evaluation 1. Weight loss CBC, albumin, ESR, CRP, and coeliac serology 2. Deceleration of linear growth 3. Delayed puberty 4. Signi \201 cant vomiting LFTs, amylase, lipase, UA, and abdominal ultrasound Education and reassurance Education is a vital foundational component of basic in-offi ce c are for children with FGIDs. Providing a clear explanation of FGIDs \200\224 including the reassuring messages that the child \200\231s pain is under- stood, that it is not dangerous , and that there is something that can be done about it \200\224can be very helpful in decr easing anxiety and further healthcare seeking in both the parent and child (Di Lorenzo et a l., 2005 a). Further, clearly communicating the biopsychosocial nature of FGIDs helps provi de a context for the multicomponent approach to treatment, thereby improving patient/family willing- ness to adhere to the recommended treatments and setting the stage for acceptance of later subspecialty referrals, if needed. In fact, there is some evidence that children whose parents accept a biopsychosocial conceptualization of abdominal pain and its treat- m ent are more likely to experience symptom improvement (Scholl and Allen, 2007 ). 5. RUQ pain/tenderness 6. Haematemesis or haematochezia CBC, ESR, CRP, coeliac serology, stool exam for pathogens, and endoscopy 7. RLQ pain/tenderness 8. Chronic severe diarrhea 9. Perianal disease or oral lesions 10. Systemic symptoms including unexplained fever, unexplained rash, or arthritis 11. Family history of IBD or coeliac disease 12. Dysphagia Barium swallow and endoscopy CBC = complete blood count; CRP = C-reactive protein; ESR = erythrocyte sedimentation rate; IBD= in \202 ammatory bowel disease; LFT = liver function test; RLQ = right lower qu adrant; RUQ = right upper quadrant; UA = urinalysis. Medication While education and reassurance are universal, medication man- agement varies by specifi c FGID. However, evidence for most of the current medications in use has been obta ined from studies in adults; only a small number of controlled studies in children cur- ren tly exist. that determination), there is a biological pathway which translates the central stress resp onse into gastrointestinal symptoms. It seems likely that, in the end, the value of testing will not be in making a diagnosis of an \200\230organic \200\231 disease but in identifyi ng the biologi- cal factors (e.g. mucosal infl ammation, dysmotility, and/or visceral hyper sensitivity) contributing to the generation of symptoms and which might be amenable to spec ifi c treatments. Th is may account for recent fi ndings that endoscopy results in a change in manage- ment in two-thirds of children with abdominal pain (Th akkar et al., 2011 ). In adults with IBS, tricyclic antidepressants (TCAs), selective serotonin reuptake inhibito rs (SSRIs), and antispasmodics (includ- ing cimetropium/dicyclomine, peppermint oil, pinave rium, and trimebutine) targeting visceral hypersensitivity and/or dysmotil- ity, but not bu lking agents, are eff ective (Ford et al., 2009 ; Ruepert et al., 2011 ). Th ere have been only two controlled pediatric trials assessing TCAs for FGIDs and no trials for SSRIs. Amit riptyline was ineff ective in the larger trial which included FD, FAP, and IBS patients (Sa ps et al., 2009 ). In the other trial, which included only IBS patients, amitriptyline trea tment was associated with decreased diarrhea and pain (Bahar et al., 2008 ). Other than a s ingle trial of peppermint oil, there are no controlled trials of antispasmodics in pediatri c IBS (Kline et al., 2001 ). It appears that fi bre has no sig- nifi cant eff ect on pain i n children with IBS (Huertas-Ceballos et al., 2009 ). Antibiotics have been shown to be eff ective for non-consti- pated IBS in adults, but have not been evaluated in children (Basse ri et al., 2011 ). Two controlled studies support the use of probiotics ( Lactobacillus rha mnosus GG) in children with IBS (Francavilla et al., 2010 ; Gawro \204 ska et al., 2007 ). Reasonable initial options based on the existing evidence would include daily low-dose TCA s (e.g. amitriptyline; 0.3 mg/kg given at bedtime) with antispasmodics (e.g. dicyclomine or peppermint oil) given on an as-needed basis, antibiotics directed at small bowel bacterial overgrowth (e.g. met- ronidazole or rifaximin), or probiotics for diarrhea-predominant IBS and a laxative with an SSRI for constipation-predominant IBS. Identifi cation of psychosocial factors that may be contributing to symptom generation, and that may be appropriate targets of treat- ment, also is pivotal as part of the initial cli nical workup. To that end, brief self- and/or parent-report measures can be employed within a busy clinical setting to quickly screen for areas of concern and prioritize treatments a s part of the initial clinical approach. Many validated questionnaires are available to ass ess issues common in children with FGIDs, such as psychological functioning, parent behavio r, sleep, and functional disability, among others (see sup- plementary material online for a list of questionnaires to consider by area). In addition, relevant information about scho ol (e.g. attend- ance, perceived barriers, learning history) may be elicited quickly via a few targeted questions posed during the medical history. Treatment To date, no evidence-based guidelines exist for the treatment of chronic abdomina l pain, in general, or for any specifi c FGID- related to pain in children. Th e current em phasis is on treating CHAPTER 29 recurrent abdominal pain 293 Seventy-two per cent of pediatric gastroenterologists treat FD empirically (before endoscop y) with acid reduction therapy (Schurman et al., 2010 a). H2 antagonists, proton pump inhib itors (PPIs), and prokinetics have been found to be superior to placebo in the treatment of FD in adults (Moayyedi et al., 2006 ). Only one small trial of acid suppression has been p ublished in pediatric FD, in which famotidine was shown to be superior to placebo in global pain resolution (See et al., 2001 ). Prokinetics have not been evalu- ated for FD in child ren. Reasonable initial options based on the existing evidence would be an H2 antagonist or a PPI (especially if there are refl ux symptoms) when pain is the predominant symptom or a prokinetic agent targeting dysmotility when pain is not the pre- dominant symptom (e.g. mo re problems with nausea or bloating). Outside of IBS and FD, there are two other controlled trials involving pain-associated FGIDs in children. Cyproheptadine was found to improve in tensity and frequency of pain in children with FAP (Sadeghian et al., 2008 ). Pizotifen, wh ich is not approved in the US, has been demonstrated to have effi cacy in the treatment of abdominal migraine (Symon and Russell, 1995 ). Frequently pre- scribed medications for abdo minal migraine include propranolol, cyproheptadine, and sumatriptan though these have not b een eval- uated in controlled trials in children. (see supplementary material online for a handout covering a vari- ety of behavioral coachin g points). School accommodation Many children with chronic abdominal pain have school probl ems. Th ey may miss school days (or even weeks) because of symptoms, doctors \200\231 visit s, or hospitalizations. Th ey also may get behind in daily school work, have a hard time pa ying attention in class, suff er social embarrassment related to frequent trips to the toil et, or feel over- whelmed by makeup work. Accommodations that can be helpful in terms of su pporting patients \200\231 success at school and encouraging their regular attendance inclu de: allowing easy access to the toilet, encouraging brief breaks for use of stress and pain management skills, allowing participation in clubs and sports while working on getting bac k to school, and carefully considering makeup work and the timeline for its completion. Hel ping families initiate a formal plan according to local regulations (e.g. Section 504 Plan in the US, Educational Statement in the UK) for a patient \200\231s health issues can be be nefi cial to formalize these accommodations and encourage consistent participation across a ll school staff . Additionally, when children have been out of school for a long period of time due to their abdominal pain and/or other physical symptoms, a gradual and structured r eturn to the classroom may be an important part of the treatment plan. Approaching return t o school in this fashion has the advantage of reducing patients \200\231 fear and avoidance , while reintegrating patients into age-appropriate academic/social activi- ties and redire cting attention from symptoms toward functioning (Walker, 2004 ; Walker et al., 2009 ). Bal ancing demands with sup- port is vitally important, as stress can increase pain and have an overall negative eff ect on the recovery process. Although variations on a graduated appro ach to school re-entry likely exist, the three key steps include: (1) choosing a block of t ime the patient is able to attend every day without increased symptoms, (2) the patient att ending school for the agreed upon amount of time (no more, no less), regardless of pain, an d (3) regularly evaluating the patient \200\231s progress to determine when and how much ad ditional class time to add (see supplementary material online for a sample approach). Regardless of FGID, infl ammation with eosinophils and/or mast cells represents a potential therapeutic target. Infl ammation may be documented (e.g. duodenal eosinophils in FD) or s uspected based on clinical profi le (e.g. mast cells in an anxious D-IBS patient). Monteluk ast has been shown to be eff ective in children with FD in association with duodenal eosino philia (Friesen et al., 2004 ). Other options targeting eosinophils and mast cells include combination of H1 and H2 antagonists (e.g. ranitidine and hydroxyzine) and oral cromolyn as a mast cell-stabilizing agent (Friesen et al., 2006 ; Stefanini et al., 1995 ). Behavioral coaching Parental education and skills training is a critical component of in-offi ce care of chronic abdominal pain patients. Parents can be coached to maintain behavioral expectat ions for their child \200\231s par- ticipation in school and other activities (Scholl and A llen, 2007 ). Participating in normal daily activities, even when in pain, gives children a sense of control over the pain; as children feel more in control, anxiety (and the associa ted stress response) oft en will decrease. It is important to note that while some form of daily activ- ity is critical to long-term health and recovery, overdoing it can complicate and prolong the symptom course. Emphasis should be placed on preventing further declines in functioning and on gradu- ally and systematically increasing daily expectations from whate ver point the child is currently. Parents should be taught to encour- age and model good co ping with pain symptoms (Scholl and Allen, 2007 ). Parents can gently remind and encourage children to use skills like deep breathing, distraction, relaxation, positive think- ing, e tc. during pain episodes, or before events that seem to trig- ger pain (e.g. eating, going to school, having a test). Parents can be encouraged to provide attention and praise (or ot her rewards) for children \200\231s demonstration of good coping and/or well behaviors (e.g . using relaxation, attending a portion of the school day), and to ignore and minimize atte ntion paid to symptom complaints and non-verbal pain behaviors (Crushell et al., 2003 ). Re lated to this, providers can reassure parents that it is okay, and indeed preferable, not t o regularly inquire about their child \200\231s pain. Pain is worse when children pay atten tion to it and better if they are distracted from it Collaboration with ancillary services For a subset of children, in-offi ce care will be ins uffi cient to resolve the child \200\231s pain and/or disability. When this occurs, it may be help- ful to refer the child for additional subspecialty treatment as part of the compre hensive treatment package. Maintenance of regular follow-up in the primary care offi ce is vital, as is close collaboration with any subspecialty providers involved to ensure ongoing coordi- nation of care and consistency of messages to the family. Some of these subspecial ty services have an evidence base to support their use in children with FGIDs, while others are based on more theo- retical or practical concerns. Th e three ancillary services with the most, albeit still limited, empirical support are co gnitive-behavioral therapy, hypno- therapy, and biofeedback-assisted relaxation training (B ART; Brent et al., 2008 ). All three services, as applied to FGIDs, focus on changing thoug hts and/or behaviors in the interest of alleviat- ing physical symptoms. While these servic es also may help with subclinical anxiety, they primarily target pain management and behavi oral activation; they are not geared to address major men- tal health disorders. When refer ring out for these services, it may be helpful to communicate expectations directly to the collabo- rating provider prior to, or at the onset, of care. Oft en, children SECTION 4 pain in specific populations and diseases 294 with FGIDs do not have a diagnosable mental health disorder. As such, community providers w ithout specifi c pediatric or health psychology training may not be certain of their role i n the treat- ment plan and/or may not be experienced enough to know how to initiate treatme nt. and point to the possibility of inpatient treatment as a unique and eff ective treatment ch oice for children severely disabled by chronic pain, controlled treatment studies of intens ive day treatment or inpatient pain rehabilitation remain sorely needed to justify the sign ifi cant cost of these programs. Certainly, when more substantial mental health issues are appar- ent, referral for individu al therapy, psychiatry, and/or family ther- apy may be helpful. Even if these issues have a risen secondary to the onset of pain, mental health issues can be a signifi cant source of emotional and social stress that may play a further contributory role in maintenance of pai n and disability. Similarly, psychoeduca- tional evaluation of learning issues may be helpf ul for a subset of children who have a history of academic performance concerns. More subtl e learning issues may not be diagnosed until later in elementary school or beyond, as workl oad demands increase and exceed the individual \200\231s ability to compensate. Conclusion With the current absence of specifi c clinical practice guidelines for assessmen t and treatment of pediatric recurrent abdominal pain, or FGIDs more specifi cally, the bes t available approach is one con- sistent with the widely accepted biopsychosocial model. Em phasis on early identifi cation and treatment of all factors (i.e. biological, psychologica l, and social) that may be playing a contributory role in pain maintenance will provide the best opportunity for eff ective intervention and prevention of long-term issues. Additiona l research in this area \200\224with particular emphasis on using current diagnostic classi fi cation systems to defi ne samples, employing rigorous meth- odologies for execution of c linical trials, and attempting to identify the most powerful or necessary components of mul ticomponent treatment packages \200\224will be necessary to improve the quality and consist ency of care provided to this pediatric pain population. In some cases, in which children have been physically inactive for a prolonged period of ti me, or are resistant to increasing physi- cal activity and engagement, a brief course of ph ysical therapy may be benefi cial to increase muscle tone, fl exibility, and/or stamina. A home exercise plan based on the child \200\231s current level of physical conditioning and the desired activity goal (e.g. walking around the school building without diffi culty, ret urn to competitive sports) can be helpful in structuring the child \200\231s physical rehab ilitation, as well as providing parents with tangible daily expectations that may be built into the behavioral contingency plan. Other alternative treat- ments, such as therapeutic m assage and acupuncture, also may be benefi cial in a subset of children with FGIDs to promo te pain relief and recovery of function. Again, referral for many of these treat- ments wil l be based purely on practical concerns related to a given child, including the perceived a cceptability of one treatment versus another, as the evidence base remains quite limited. Case example Tyler, an 11-year-old boy, was evaluated for a 2-year history of daily abdominal pain, with associated complaints of nausea, bloat- ing, and early satiety. His clinical history was p ositive for asthma, seasonal allergies, attention defi cit hyperactivity disorder, and sign ifi cant problems with sleep duration and quality. Tyler was being home-schooled and missed extracurricular/social activities several times per week due to pain. Past medical history included evaluation by a gastroenterologist and a naturopathic practitioner, with extensiv e laboratory testing plus upper and lower endoscopy. Review of Tyler \200\231s previous wor kup revealed normal lab fi ndings, but increased duodenal eosinophil counts on endoscopic b iop- sies. He had been tried on multiple medications and followed a restricted diet without signifi cant symptom relief. Intensive outpatient/inpatient rehabilitation In the event that coordinated outpatient trea tment as already described is not suffi cient \200\224that is, a child continues to experi- ence signifi cant pain symptoms and, more importantly, continues to suff er precipitous de clines in his or her functioning \200\224a higher level of treatment may be needed. Intensi ve day treatment or inpatient pain rehabilitation programs may represent a useful model of care in these cases. Such programs typically utilize all of the modalities previously descr ibed, albeit in a more struc- tured, controlled environment to help patients and their pare nts to \200\230walk the walk \200\231 in real time and in the context of a supportive, the rapeutic environment. Th e ultimate goal for these patients is to return to their homes, sc hools, and friends and transition back to their outpatient care team for monitoring and bui lding upon gains made. Tyler \200\231s evaluation and initial treatment took place over a period of approximately 4 months. A few of the components considered pivotal in Tyler \200\231s treatment are highl ighted here. Tyler was diag- nosed with FD using the Rome III criteria. In addition to anti - histamines and montelukast, he was prescribed oral cromolyn four times daily to address t he identifi ed infl ammatory compo- nent of his abdominal pain. Tyler also was referred to a certifi ed biofeedback practitioner near his home. He attended BART ses- sions three time s per week initially and practiced the skills several times per day at home. Tyler \200\231 s family utilized a structured plan for graduated school re-entry, starting by attending on e consist- ent class period daily and gradually adding time to his in-school schedule as st amina increased. During this process, Tyler also received instruction from a homebound teac her in the classes he was not yet attending. As specifi c classes were added to his in-scho ol schedule, support for these classes was dropped from homebound and the amount of homebou nd instruction was reduced. Accommodations also were put in place that allowed Tyler to tak e breaks for BART practice and to use the toilet, as needed, during the school day. Unfortunately, only a few, uncontrolled studies have examined the eff ectiveness of such pr ograms. Results from three prospec- tive studies of two diff erent 3-week multidisciplinary inpatient pro- grammes for pediatric chronic pain suggested improvements in pain intensity , pain-related disability, and school attendance, as well as in patients \200\231 emotional distress and pain-related coping (Eccleston et al., 2003 ; Hechler et al., 2009 , 2010 ). A recent retrospective review of an inpatient pediatric pain treatment program also documen ted improvements in school status, sleep, functional dis- ability, physical mobility, and m edication usage aft er a mean stay of 27 days (Maynard et al., 2010 ). While these results are encouraging CHAPTER 29 recurrent abdominal pain 295 Claar , R. L. , Walker , L. S. , and Smith , C. A. ( 1999 ). Functional disability in adole scents and young adults with symptoms of irritable bowel syndrome: the role of academic, so cial, and athletic competence . J Pediatr Psychol , 24 , 271 \200\223280. Routine in-offi ce follow-up continued on a regular basis to monitor progress, provide beha vioral coaching, support contin- ued engagement in treatment components, and modify the pla n as needed. Aft er 1 month of treatment, Tyler reported that BART was extremely helpful to him in terms of helping to manage his pain. Aft er 4 months of treatment, Tyler reported h aving abdom- inal pain about once per week. His appetite, sleep, energy, and headaches also were improved. Within approximately 8 weeks of beginning graduated school re-entry, Tyler was attending school full time and participating in social activities with his peers. Crushell , E. , Rowland , M. , Doherty , M. , Gormally , S. , Harty , S. , and Bourke , B. E. ( 2003 ). Importance of parental conceptual model of illness in severe recurrent abdomin al pain . Pediatrics , 1368 \200\2231372. Devanarayana , N. M. , De Silva , D. G. H. , and De Silva , H. J. ( 2008 ). Gastric myoelec trical and motor abnormalities in children and adolescents with functional recurrent abdomi nal pain . J Gastroenterol Hepatol , 23 , 1672 \200\2231677. Devanarayana , N. M. , Mettananda , S. , Liyanarachchi , C. , Nanayakkara , N. , Perera , N . , and Rajindrajith , S. ( 2011 ). Abdominal pain-predominant functional gastrointestinal diseases in children and adolescents: prevalence, symptomatology, and association with emot ional stress . J Pediatr Gastroenterol Nutr , 53 , 659 \200\223665. It is important to convey the fact that Tyler \200\231s recovery was not perfectly linear, nor has it ended. Although not yet substanti- ated in the literature, clinical experience h as suggested that eosinophilic infl ammation within the gastrointestinal tract is especiall y sensitive to viral illnesses, seasonal allergies, and stress. Consistent with this, Tyler evidenced temporary symptom fl ares at predictable times during his treatment. While certa inly disap- pointing for Tyler and his family, these setbacks provide impor- tant clues for preventing, or at least managing, fl ares when they occur. Proper hand washing to reduce t ransmission of viruses, aggressive treatment of seasonal allergies, and advance plan- ning to reduce stress can be helpful in reducing the odds of a temporary increase in gastrointes tinal infl ammation and associ- ated symptoms. Identifying and addressing potential trigger s for future episodes can be an important part of long-term mainte- nance for an individual child. Devanarayana , N. M. , Rajindrajith , S. , Rathnamalala , N. , Samaraweera , S. , and Benni nga , M. A. ( 2012 ). Delayed gastric emptying rates and impaired antral motility in childr en fulfi lling Rome III criteria for functional abdominal pain . Neurogastroenterol Motil , 24 (5), 420 \200\223425.