The definitions of the study designs were as follows: uncontrolled experiment an unspecified group of participants received intervention and follow-up data were provided; case-series cross section data were provided on a single group of participants; case-series follow-up baseline and follow-up data were provided on a single group of participants; cohort cross section a single group of participants was divided into 2 or more groups on the basis of a specified feature (e.g. history or laboratory tests) and described; cohort follow-up baseline and follow-up data were provided on a single group of participants who were divided into 2 or more groups; case control 2 or more groups were assembled and retrospective or current data are provided; and randomized controlled trial (RCT) participants were randomly assigned to intervention and follow-up data are provided. Because the questions were all comparative only studies with 2 arms or more were included in this review (thereby excluding case series).

Table 3 of the technical report (see "Availability of Companion Documents" field) shows the type of articles and studies as processed in the review. Most articles were rejected on the basis of title review. Some articles were rejected at more than 1 point in the process as indicated by the overlaps. Ninety-four articles were left for review. Sixty-four articles had full data investigation which included separating articles into 1 or more studies in case there was for example a baseline case-control study with a cohort follow-up; hence the 64 articles translated into 83 studies.

An article might have more than 1 study in it if for instance there was an initial cohort cross-section with a subsequent cohort follow-up reported in the same article. Of the 83 studies for which methodology was reviewed 46 were case control 20 were cohort cross section 10 were cohort follow-up and 7 were RCTs. A recent systematic review of treatments in recurrent abdominal pain identified the same RCTs providing validation for this approach.

Data abstracted for each study as a whole included study city; study country; single or multiple site; site type (community physician office academic pediatric setting gastroenterologist office); funding source; age range mean and standard deviation (SD); sample size; number of groups; number of outcomes; and number of time points.

A methodology review was performed for each study based on the Newcastle-Ottawa Scale for assessing the quality of nonrandomized studies in meta-analyses. Inclusion and exclusion criteria were noted by using the controlled vocabulary. The evidence was characterized in terms of outcome type (based on the controlled vocabulary) outcome name (specific to this study) outcome units (for continuous outcomes) outcome time point (baseline or later) method (how outcome was assessed) sample size at outset and sample size at termination (a difference from sample size at outset indicated loss to follow-up). Data for continuous outcomes (in which a quantity was measured within a participant) were usually characterized by the mean and SD. For categorical data (in which participants were counted once) the category was labeled by using the controlled vocabulary test statistic name P value (and comments) and data source (page/figure/table).

Figure 1 of the technical report summarizes the geographic distribution of the studies for which the country was provided. Of 89 articles for which data were provided 62 (70%) were performed at a single site 30 (34%) were based on research at an academic pediatric center 27 (31%) were performed at a gastroenterology clinic 17 (19%) were performed at the community level and 9 (10%) were performed at general pediatric offices.

The guideline developers calculated a quality score for each study as the ratio of quality items attained to the total number of items. The average SD and confidence intervals are given for each design in Table 4 of the technical report. Although the quality scores seem to increase for the more preferred designs the confidence intervals all overlap.

Evidence tables for each of the 8 questions were generated across studies and grouped according to arm type method or outcome as pertinent to the question. There were 685 outcomes across the studies categorized as history outcomes (550 [80%]) tissue/physiologic outcomes (115 [17%]) physical examination outcomes (15 [2%]) and use of medications (5 [1%]). Among the 685 outcomes 161 of the P values (23%) were not statistically significant and an additional 316 (46%) were not provided by investigators. Each subcommittee member took responsibility for 1 or more questions. Each reviewed the evidence tables and the primary articles and generated a summary of the research. The scale for rating evidence is described in "Rating Scheme for the Strength of the Evidence."

The reviews were discussed by the subcommittee and the nominal group technique was used to achieve consensus.

Methods Used to Formulate the Recommendations

Expert Consensus (Nominal Group Technique)

Description of Methods Used to Formulate the Recommendations

The guideline-development process of Woolf was used with a subcommittee of experts and community physicians guiding the work of the methodologist (H.P.L.) to assemble the evidence reviewing the results of the methodologist and using the nominal group technique to arrive at conclusions based on the evidence.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation

Peer Review

Description of Method of Guideline Validation

Not stated

Major Recommendations

Recommendations

1. The term "recurrent abdominal pain" as currently used clinically and in the literature should be retired. Functional abdominal pain is the most common cause of chronic abdominal pain. It is a specific diagnosis that needs to be distinguished from anatomic infectious inflammatory or metabolic causes of abdominal pain. Functional abdominal pain may be categorized as one or a combination of: functional dyspepsia irritable bowel syndrome abdominal migraine or functional abdominal pain syndrome (see table below titled "Recommended Clinical Definitions of Long-Lasting Intermittent or Constant Abdominal Pain in Children").
2. Functional abdominal pain generally can be diagnosed correctly by the primary care clinician in children 4 to 18 years of age with chronic abdominal pain when there are no alarm symptoms or signs the physical examination is normal and the stool sample tests are negative for occult blood without the requirement of additional diagnostic evaluation.
3. The presence of alarm symptoms or signs including but not limited to involuntary weight loss deceleration of linear growth gastrointestinal blood loss significant vomiting chronic severe diarrhea persistent right upper or right lower quadrant pain unexplained fever family history of inflammatory bowel disease or abnormal or unexplained physical findings is generally an indication to pursue diagnostic testing for specific anatomic infectious inflammatory or metabolic etiologies on the basis of specific symptoms in an individual case. Significant vomiting includes bilious emesis protracted vomiting cyclical vomiting or a pattern worrisome to the physician. Alarm signs on abdominal examination include localized tenderness in the right upper or right lower quadrants a localized fullness or mass effect hepatomegaly splenomegaly costovertebral angle tenderness tenderness over the spine and perianal abnormalities.
4. Testing may also be performed to reassure the patient parent and physician of the absence of organic disease particularly if the pain significantly diminishes the quality of life of the patient.
5. The child with functional abdominal pain is best evaluated and treated in the context of a biopsychosocial model of care. Although psychological factors do not help the clinician distinguish between organic (disease-based) and functional pain it is important to address these factors in the diagnostic evaluation and management of these children.
6. Education of the family is an important part of treatment of the child with functional abdominal pain. It is often helpful to summarize the child's symptoms and explain in simple language that although the pain is real there is most likely no underlying serious or chronic disease. It may be helpful to explain that chronic abdominal pain is a common symptom in children and adolescents yet few have a disease. Functional abdominal pain can be likened to a headache a functional disorder experienced at some time by most adults which very rarely is associated with serious disease. It is important to provide clear and age-appropriate examples of conditions associated with hyperalgesia such as a healing scar and manifestations of the interaction between brain and gut such as the diarrhea or vomiting children may experience during stressful situations (e.g. before school examinations or important sports competitions).
7. It is recommended that reasonable treatment goals be established with the main aim being the return to normal function rather than the complete disappearance of pain. Return to school can be encouraged by identifying and addressing obstacles to school attendance.
8. Medications for functional abdominal pain are best prescribed judiciously as part of a multifaceted individualized approach to relieve symptoms and disability. It is reasonable to consider the time-limited use of medications that might help to decrease the frequency or severity of symptoms. Treatment might include acid-reduction therapy for pain associated with dyspepsia; antispasmodic agents smooth muscle relaxants or low doses of psychotropic agents for pain or nonstimulating laxatives or antidiarrheals for pain associated with altered bowel pattern.
9. Additional research is needed to fill the large gaps of knowledge on chronic abdominal pain in children.

Clinical Algorithm(s)

None provided

Type of Evidence supporting the Recommendations

Of the 83 studies for which methodology was reviewed 46 were case control 20 were cohort cross section 10 were cohort follow-up and 7 were randomized controlled trials (RCTs).

Potential Benefits

Appropriate evaluation and management of chronic abdominal pain in children and adolescents

Potential Harms

Not stated

Qualifying Statements

The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations taking into account individual circumstances may be appropriate.

Description of Implementation Strategy

An implementation strategy was not provided.

IOM Care Need

Living with Illness

IOM Domain

Effectiveness
Patient-centeredness

Bibliographic Source(s)

• Chronic abdominal pain in children. Pediatrics 2005 Mar;115(3):812-5. [13 references] PubMed

Adaptation

Not applicable: The guideline was not adapted from another source.

Source(s) of Funding

American Academy of Pediatrics

Guideline Committee

Subcommittee on Chronic Abdominal Pain

Composition of Group that Authored the Guideline

Subcommittee on Chronic Abdominal Pain: Carlo Di Lorenzo MD Co-chairperson; Richard B. Colletti MD Co-chairperson; Harold P. Lehmann MD PhD; John T. Boyle MD; William T. Gerson MD; Jeffrey S. Hyams MD; Robert H. Squires Jr MD; Lynn S. Walker PhD

Staff: Pamela T. Kanda MPH

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

All clinical reports from the American Academy of Pediatrics (AAP) automatically expire 5 years after publication unless reaffirmed revised or retired at or before that time.

Guideline Availability

Electronic copies: Available from the American Academy of Pediatrics (AAP) Policy Web site.

Print copies: Available from American Academy of Pediatrics 141 Northwest Point Blvd. P.O. Box 927 Elk Grove Village IL 60009-0927.

Availability of Companion Documents

The following is available:

• Subcommittee on Chronic Abdominal Pain. Technical report. Chronic abdominal pain in children. Pediatrics 2005 March;115(3):e370-81.

Electronic copies: Available from the American Academy of Pediatrics (AAP) Policy Web site.

Print copies: Available from American Academy of Pediatrics 141 Northwest Point Blvd. P.O. Box 927 Elk Grove Village IL 60009-0927.

Patient Resources

None available

NGC STATUS

This NGC summary was completed by ECRI on March 23 2005.

COPYRIGHT STATEMENT

This NGC summary is based on the original guideline which is subject to the guideline developer's copyright restrictions. Please contact the Permissions Editor American Academy of Pediatrics (AAP) 141 Northwest Point Blvd Elk Grove Village IL 60007.

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