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Indian Pediatrics 1999;36: 917-920

Recurrent Abdominal Pain in Indian Children and its Relation with School and Family Environment

S. Dutta , M. Mehta* and   I.C. Verma

From the Department of Pediatrics and Psychiatry*, All India Institute of Medical Sciences, New Delhi 110 029, India.
Reprint requests: Dr. S. Dutta, 141F, Mayur Vihar, Phase I, Pocket 4, New Delhi 110 091, India.
Manuscript received: August 24, 1998;
Initial review completed: October 9, 1998;
Revision accepted: March 12, 1999


Recurrent Abdominal Pain (RAP) in children was defined by Apley as "at least three episodes of abdominal pain severe enough to affect daily activities over a period longer than three months"(1). The prevalence of RAP in childhood ranges between 10 to 20%(1-3). An organic lesion is present in 5 to 10% of the children(1,4). RAP has been found to be common in the setting of school phobia, sibling rivalry and a family history of multiple abdominal complaints, psychological problems and disturbed interpersonal relationships.(1,4-7). Although there are Indian studies which have looked at organic causes including Helicobacter pylori, there is scant data on the psychosocial correlates of RAP(8-11). Our objective was to determine which aspects of school and home environment are associated with non-organic RAP (NORAP) in Indian children.

Subjects and Methods

Children aged 5 to 14 years attending the Pediatric Outpatient Department, at the All India Institute of Medical Sciences, who were suffering from RAP, were enrolled after parental consent. Following detailed history and physical examination, the patients were subjected to routine tests that included complete blood counts, urine examinations (done thrice), stool examinations (done thrice) and a plain x-ray of the abdomen. Special investigations were performed whenever indicated. Children who had a probable organic cause were treated accordingly and were followed up for a period of at least three months. Only those patients who satisfied all the following criteria were considered to be suffering from ORAP: (i) An organic cause was demonstrated; (ii) There was clinical and laboratory evidence of response to treatment; and (iii) there was sustained clinical remission for at least three months after therapy. The patients who did not satisfy the above criteria were considered to have NORAP and were compared with an equal number of age and sex-matched controls, that comprised of children attending the Pediatric Outpatient Department with recurrent upper respiratory tract infections.

All children with RAP and the control group were administered a structured pro-forma which included items on demographic data, clinical details of abdominal pain, family environment and school environment.

Results

Fifty patients satisfied the inclusion criteria. Of these 13 (26%) were identified to be suffering from ORAP. The remaining 37 patients had NORAP, and they were age and sex matched with an equal number of controls. Of the 13 patients with a final diagnosis of ORAP, 4 had peptic ulcer, 4 parasitic infestations, 3 abdominal epilepsy, 1 vesico-ureteric reflux and 1 urinary tract infection.

The demographic data of the three groups, namely NORAP, ORAP and controls were similar. Nearly half the patients in all the three groups were aged more than 10 years.

The commonest pattern of abdominal pain was recurrent episodes of periumbilical pain of a steady non-radiating character, each lasting 5 to 30 minutes, and occurring daily with no specific aggravating or relieving factors. (Table I). The characteristics of pain by themselves did not differentiate organic and non-organic RAP. Intereference with sleep was significantly more common among patients with ORAP.

Forty six per cent of patients with ORAP lived in a joint family in contrast to 16% in the NORAP group and 8% in the control group (Table I). Patients with NORAP belonged to families with higher prevalence of marital discord, irritable bowel syndrome (IBS), chronic painful disorders, maternal dysmennorrhea and RAP. The 3 groups did not differ with respect to birth order, sib- ling rivalry, sibling domination, academic achievements of siblings and non-painful diseases in the family.

Tantrums before going to school, absenteeism and punishments meted out at school were more common in the NORAP group (Table II). However, the performance in school was not different between the three groups.

Table I__Pain Characteristics: Organic RAP vs Non-organic RAP

Characteristics Organic RAP(n = 13) Non organic RAP (n = 37)
1. Duration of illness  (mean ± SD, yr)

1.73 ± 1.7

2.27 ± 2.0

2. Frequency  (mean±SD, days)

6 ± 5.9

6.8 ± 9

3. Anorexia  

5 (38)

18 (49)

4. Bowel complaints

7 (54)

11 (30)

5. Interference with sleep* 

5 (38.5)

3 (8.1)

6. Nocturnal enuresis 

1 (7.7)

10 (27)

7. Generalized aches 

4 (31)

19 (51)

Unless specified all values are number of patients with percentages in parentheses .p <0.05; OR = 7.

Table II__Family and School Environment in RAP and Controls.

Parameter   

NORAP(n=37) 

ORAP(n=13)

Controls

Family . . .
1. Joint family  

6 (16)

6 (46)**

3 (8)**

2. No. of family members  (Mean±SD)

6±3.5

8.7±3.8

5.6±2.2

3. Birth order (Mean±SD) 

2±0.9

2.8±2.1

1.7±1.1

4. Marital discord  

6 (16)

2 (15)

3 (8)

5. Maternal dysmennorhea  

15 (40.5)

3 ( 23)

2 (5.4)

6. Chronic pain in family 

28 (76)

9 (69)**

7 (19)***

7. RAP in family  

5 (13.5)

1 (8)

2 (5.4)

8. IBS in family  

17 (46)

2 (15)

2 (5.4)***

9. Sibling rivalry  

17 (46)

6 (46)

7 (19)

10. Beating used for disciplining 

8 (21.6)

1 (8)

3 (8)

School . . .
11. Tantrums before school  

20 (54)

3 (23)

2 (5.4)***

12. Absenteeism  

15 (41)

2 (15)*

2 (5.4)***

13. Frequent punishment   

8 (22)

2 (15)

1 (2.7)*

14. Performance Grade A,B 

9 (51)

1 7 (54)

19 (51)

* p < 0.05; ** p < 0.01; *** p < 0.001.

p-values are given for comparison between the NORAP group and the control or ORAP group.

Unless specified all values are number of patients with percentages in parentheses

Discussion

Our study, like most studies from the West, showed that patients with NORAP were living in a different psychosocial environment at school and home compared to patients with ORAP and the control patients(1-4) This may have a role in the genesis of pain in these pateints. Not only was their environment more stressful, they also had role models of chronic recurrent pain within the family. Patients with ORAP lived in larger joint families where overcrowding may account for a higher prevalence of parasitic and other infections, which can cause RAP. The frequency of ORAP in our study was slightly higher than that in Western studies. Other Indian studies have shown a higher prevalence of organic causes of RAP, and also an association between H. pylori and RAP(8-11). The relation between H. pylori infection and RAP in children has been widely debated in recent years but a meta-analysis of 45 studies has shown that H. pylori is not associated with RAP(12).

The mean duration of illness at the time of presentation was longer in the NORAP group possibly because patients with ORAP have their causes identified at some stage. Patients with functional disorders often have symptoms that closely mimic organic illnesses, hence it is not surprising that the characteristics of the pain were largely similar in both the groups. The interference with sleep in the ORAP group is expected, as most functional disorders do not interfere with sleep patern(5). Nocturnal enuresis, a problem with a psychological basis, is understandably commoner among patients with NORAP(1).

The number of patiens in the ORAP group are small, and hence the statistical significance of the comparisons with ORAP is limited. As there are no prevalidated Indian questionnaires that address the issues of interest to us, we had to use structured proformas.

We conclude that the basis of non- organic RAP in Indian children seems to be an underlying psychological instability in the patients, similar to studies in the West.

References

1. Apley J, Nalsh N. Recurrent andominal pains. A field survey of 1000 school children. Arch Dis Child. 1958; 33: 165-170.

2. Pringle MLK, Butler NR, Davie R. 11,000 Seven Year Olds. London, Longman, 1966.

3. Faull C, Nicol AR. Abdominal pain in six year olds: An epidemiological study in a new town. J. Child Psychol Psychiatr, 1986; 27: 251-260.

4. Liebman WM. Recurrent abdominal pain in children. A retrospective study in 119 patients. Clin Pediatr 1978; 17: 149-153.

5. Schmitt BD. School phobia. The great imitator: A pediatrician's viewpoint. Pediatrics 1971; 48: 433-441.

6. Woodbury MM. Recurrent abdominal pain in child patients seen at a Pediatric gastroenterology Clinic. Psychosomatics, 1993; 34: 485-493.

7. Berger HG. Somatic pain and school avoidance. Clin Pediatr 1974; 13: 819-821.

8. Gadiyar BN, Taneja PN, Ghai OP. Recurrent pain in abdomen in children. Indian J Child Health 1963; 12: 289-295.

9. Singh MV, Gupta S, Aggarwal HC. Sociopsychological basis of abdominal pain in children. Indian J Pediatr 1972; 39: 33-36.

10. Thapa BR, Chhina RS, Ayyagari A, Malik AK, Mehta S. Campylobacter pylori in children with recurrent abdominal pain. Indian J Gastroenterol 1989; 8 (Suppl); A32.

11. Kumar M, Yachha SK, Khanderi A, Prasad KN, Ayyagiri A, Pandey R. Endoscopic, histologic and microbiological evaluation of upper abdominal pain with special reference to Helicobacter pylori infection. Indian Pediatr 1996; 33: 905-909.

12. MacArthur C, Saunders N, Feldman W. Helicobacter pylori, gastroduodenal disease and recurrent abdominal pain in children. JAMA 1995; 273: 729-734.

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