To our knowledge, our study is the first to compare longitudinally the pain symptoms and bowel habits of children with RAP, and further, to compare these to normal children. Unlike previous studies of RAP ours was not just focused on children referred to tertiary care. We also were able to examine the potential relationship between episodes of pain and interference with the child’s activities.
Control children without a history of abdominal pain on the three screening steps did record episodes on pain in their two-week diary. However, the RAP group experienced more pain episodes whose mean severity and maximum intensity were greater compared with Controls ().
Although it has been suggested that the pain in RAP occurs more commonly in the morning perhaps as part of an aversion to going to school our data suggest that the pain is experienced evenly throughout the day from morning to evening () 8, 18
. Previous studies have noted that the pain in RAP is periumbilical 4, 19
. Although our data support this contention, it is important that in more than half of the cases the pain was located in other areas of the abdomen and/or in more than one location (). In addition, there was no relation between the pain location or severity of pain and the time of day the pain occurred.
Abdominal pain interferes with activities more commonly in children with RAP compared with Controls (). However, there was no difference between the groups in the level of interference. Even 15% of Control children had abdominal pain severe enough at some time that it caused interference or prevented participation in activities (). To our knowledge these findings have not been reported previously. However, they fit with the observation of Malaty et al. that pain disability is an important dimension in the development of a multidimensional measure for RAP 20
The results of the stool diaries from the Controls point out that normal children experience day to day variation in stooling pattern (). Day to day variation in stool frequency and consistency may depend on the child’s diet 21–23
. For the most part children with RAP and Controls described their stools similarly (). Approximately 15% of each group had stools that were watery or mushy. Both groups had a similar number of stools passed per day and the number of days with no stools passed also was similar between the groups (). There was no relationship between the occurrence of pain and the passage of hard stool. On the contrary, there was a significant relationship between the severity of pain and mushy stools. This could not be attributed to an intercurrent illness as none of the parents reported their children as being ill during the two week period. Studies in adults demonstrate that individuals with IBS commonly move from one functional category to another (e.g., IBS with diarrhea to FAP to IBS with constipation) although over time the IBS diagnosis is durable 24
. Our data suggest that children may follow a similar course.
Presumably stools that were reported as watery, mushy, or hard intimate that the child could meet the criteria for IBS 8
. Walker et al. had parents and children 4 – 17 years of age with RAP (n = 107) awaiting a visit to a pediatric gastroenterologist complete a symptom questionnaire 25
. Based on the responses 45% and 7.5% of the children met the Pediatric Rome II criteria for IBS and FAP, respectively 25
. However, in the definition of IBS used by this group in their retrospective study there is no reference to timing other than to say that the pain was associated with a change in stool character 25
El-Matary studied 103 children (10 ± 3.4 years of age, mean ± SD) referred to a pediatric gastroenterologist who fulfilled Apley’s criteria for abdominal pain 4, 9
. Of the children with non-organic pain, 36% met the Pediatric Rome II criteria for IBS whereas 30% had FAP 9, 25
. Using the El-Matary definition (more than 3 movements/day or fewer than 3 movements/week) we found that 42% of the children in our sample had symptoms compatible with IBS whereas 35% had FAP 9
. Differences between the results of our study and those of Walker et al. and El-Matary et al. may be explained by differences in the ages of the children, that categorization in our study was based on the two week diary versus a single episode of recall, and that their studies only examined children referred to tertiary care 9, 25
. Using our own definition of IBS (pain episode with a change in stool character that day or the day after) 65% of children in our sample had IBS and 35% had FAP.
Some qualification should be borne in mind in extrapolating our results. We studied children between 7 – 10 years of age. Whether the results apply to younger or older children needs to be established. Although detailed instructions were given to the parents and children and constant contact was maintained throughout the study period, it is possible that not all the data was filled in each day but recorded in two (or more) day blocks. However, despite this potential limitation the results should be more reliable than those based solely on long term recall.
In summary, our data point to the fact that normal children experience abdominal pain that sometimes interferes with activity and that their bowel pattern often varies. These data demonstrate the overlap in symptoms such as pain (severity, timing, location) and stool changes between children with and without RAP. The difference between RAP and Control children appears to be in the degree of symptoms rather than the symptoms themselves. Indirectly, these results support the importance of inquiring regarding the presence of other symptoms (“alarm symptoms” - e.g., weight loss, extraintestinal manifestations, fever, etc.) in identifying children with organic disease as opposed to RAP 26, 27
. The relationship between the experience of pain and the presence of mushy stools is intriguing and requires further study.