Review
Arch Dis Child: first published as 10.1136/archdischild-2020-318825 on 9 March 2020. Downloaded from http://adc.bmj.com/ on March 10, 2020 at Columbia University Libraries. Protected
1
Department of Paediatrics,
University Hospital
Southampton NHS Foundation
Trust, Southampton, UK
2
Department of Paediatric
Gastroenterology, University
Hospital Southampton NHS
Foundation Trust, Southampton,
UK
3
Department of Paediatrics,
Poole Hospital NHS Trust, Poole,
UK
Correspondence to
Dr Mark P Tighe, Paediatrics,
Poole Hospital NHS Trust, Poole
BH15 2JB, UK;
​mark.​tighe@​poole.​nhs.u​ k
Received 12 January 2020
Revised 5 February 2020
Accepted 6 February 2020
© Author(s) (or their
employer(s)) 2020. No
commercial re-­use. See rights
and permissions. Published
by BMJ.
To cite: Andrews ET,
Beattie RM, Tighe MP.
Arch Dis Child Epub ahead of
print: [please include Day
Month Year]. doi:10.1136/
archdischild-2020-318825
Functional abdominal pain: what clinicians need
to know
Edward Thomas Andrews ‍ ‍,1 R Mark Beattie ‍ ‍,2 Mark P Tighe3
Abstract
Abdominal pain in childhood is extremely common
and presents frequently to both primary and secondary
care, with many children having recurrent pain which
impacts on daily functioning. Despite this most children
have no discernible underlying pathology. We discuss
the underlying mechanism for functional abdominal
pain (visceral hypersensitivity), the evidence base linking
parental anxiety and patient symptoms, and how parents
can be supported in managing their children’s symptoms
by addressing questions commonly asked by children and
families. We look at the evidence for a one-­stop rational
approach to investigation including a coeliac screen,
inflammatory markers and consideration of stool faecal
calprotectin, in the absence of red flags. We evaluate
commonly used treatments for functional abdominal
pain, within a context of managing family expectations.
Given the limitations in pharmacological treatment
options, trials of probiotics, peppermint oil, mebeverine
and (for short-­term use only) hyoscine butylbromide may
be appropriate. Psychological interventions including
cognitive–behavioural therapy, distraction techniques
and hypnotherapy have a better evidence base. There is
also some evidence for other complementary therapies in
children, including yoga and neurostimulation. Outcome
is generally good providing there is child and family
acceptance of the multiple factors implicated in the
aetiology of the pain.
Background
The symptom of abdominal pain in childhood is so
common that it is unusual for a child to go through
school years without experiencing it at some stage.
In 1958 Apley and Naish1 reviewed 1000 healthy
school children; 10.8% reported recurrent abdom-
inal pain. The authors commented on three observa-
tions that remain pertinent: ‘First, the high incidence
of recurrent abdominal pains, especially at certain
ages and particularly in girls. Second, the high inci-
dence of abdominal pain and other complaints in
the families of affected children. Third, the lack of
evidence of any physical cause, and the positive
association of frequent emotional disturbance’.
The prevalence of functional abdominal pain (FAP)
varies, with factors including geographical location
and gender (OR for girls 1.5 compared with boys).2
The mean reported prevalence of FAP disorders in
childhood is around 13.5% (range 1.6%–41.2%).2
The high (and varied) prevalence raises the ques-
tion ‘Why are so few children diagnosed with FAP
given how common recurrent abdominal pain is?’
or appositely ‘What is different about patients diag-
nosed with an FAP disorder?’
Andrews ET, et al. Arch Dis Child 2020;0:1–7. doi:10.1136/archdischild-2020-318825
Key points
►► Functional abdominal pain is a common
presenting complaint in children.
►► Organic pathology needs to be considered but
is uncommon.
►► It is reasonable to limit investigation to a ‘one-­
stop’ targeted panel including a coeliac screen,
inflammatory markers and consideration of
faecal calprotectin.
►► Trials of probiotics, peppermint oils or
antispasmodics may be considered.
►► Cognitive–behavioural therapy, distraction and
hypnotherapy have roles to play in improving
symptomatology.
►► Gaining parental and child acceptance of the
functional nature of pain is key.
The prevalence of abdominal pain in the commu-
by copyright.
nity is far higher than seen in clinical practice.3 It
is important to remember that almost 90% of chil-
dren presenting with abdominal pain to primary
care have no discernible organic pathology.4 The
presence of ‘red flags’ (Box 1) does significantly
increase the likelihood of organic pathology, and
the absence of ‘red flags’ makes organic disease less
likely, even when pain is severe and causes signifi-
cant disability.
Characterisation and classification of FAP and
functional gastrointestinal disorder (FGID) have
been updated, with the Rome IV classification being
the most recent. Rome IV FGIDs include functional
dyspepsia, irritable bowel syndrome (IBS), abdom-
inal migraine and FAP- not otherwise specified
(NOS) (table 1).5 The update reduces the emphasis
on investigations and FAP being a diagnosis of
exclusion, permitting an approach of limited, selec-
tive or no testing to support a diagnosis of FAP
disorder.5
The diagnostic criteria for FAP-­NOS include all
of the following:
►► Episodic or continuous abdominal pain that
does not occur solely during physiological
events (eg, eating, menses).
►► Insufficient criteria for IBS, functional dyspepsia
or abdominal migraine.
►► After appropriate evaluation, the abdominal
pain cannot be fully explained by another
medical condition.
►► Some loss of daily function must also be present,
although FAP-­ NOS can exist with additional
somatic symptoms (such as headaches and
sleeping difficulties).
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Arch Dis Child: first published as 10.1136/archdischild-2020-318825 on 9 March 2020. Downloaded from http://adc.bmj.com/ on March 10, 2020 at Columbia University Libraries. Protected
of psychological factors contributing to illness in children who
Box 1 Alarm features/red flags in children with chronic recovered from FAP than in those with refractory pain (OR 47.7;
abdominal pain 95% CI 3.5 to 1511.6).10 It is well accepted that parental distrac-
tion rather than attention can reduce symptom severity9; this
►► Family history of inflammatory bowel disease, coeliac disease
was demonstrated by assigning parents to attention, distraction
or peptic ulcer disease. or no instruction after a water load symptom provocation task
►► Persistent right upper or right lower quadrant pain.
in 223 children, with the distraction group reporting improved
►► Dysphagia.
pain (mean pain score=15.48, SE=0.59) compared with the
►► Odynophagia.
attention group (mean pain score=2.35, SE=0.61; p<0.01).9
►► Persistent vomiting.
There are data suggesting cognitive–behavioural therapy (CBT)
►► Gastrointestinal blood loss.
in parents of children with FAP reduces symptomatology in chil-
►► Nocturnal diarrhoea.
dren by reducing protective parenting responses and increasing
►► Arthritis.
child coping skills.11 12
►► Perirectal disease.
Clinical bottom line: FAP is multifactorial, with the child’s
►► Involuntary weight loss.
personality and family response to symptoms influencing severity
►► Deceleration of linear growth.
and impact. Anxiety and parental attention affect symptoms
►► Delayed puberty.
adversely, and familial acceptance and supporting child coping
►► Unexplained fever.
skills improve symptoms.
Adapted from Hyams et al.5
What about visceral hypersensitivity?
Visceral hypersensitivity describes a state of heightened sensitivity
Clinical Questions to normal gut activity.12 Visceral hypersensitivity is increased in
What is the evidence that psychosocial factors are relevant to both inflammation and states of psychological stress13; there is
the presentation and resolution of symptoms? limited evidence that the degree of visceral hypersensitivity is
​ he sorrow which has no vent in tears may make other organs
T related to symptom severity.14 Visceral hypersensitivity is felt to
weep. (Henry Maudsley 1835–1918) play a significant role in the aetiology of FAP, and its reduction,
There is a well-­established link between FAP and anxiety. One by alleviating triggers, is felt to be a potential contributor to
study of 479 children with FAP found a 51% lifetime risk of treatment success with therapies such as probiotics.15
anxiety disorders, significantly higher than controls (20% life-
time risk).6 Personality traits of children with FAP who have

by copyright.
What is the role that stress plays in symptom severity?
higher levels of functional impairment are identified as that of
Numerous studies clearly demonstrate the link between stress,
being anxious and perfectionistic.1 7 Coexisting anxiety disorders
physical and psychological, and the reporting and symptom
in children and parents are predictive of the trajectory of the
severity of FAP.2 16 17 Symptom scores are improved in patients
child’s symptomatology.6 7 Discussing parents’ fears, concerns
who are exposed to hypnotherapy, CBT and other psychological
and coping strategies can help in acknowledging how parents
interventions.11 13 18 It is important to be clear that stress can be
are affected.8 Parental reinforcement and potential modelling
physical and/or psychological.
of ‘the sick role’ increase the likelihood of persisting functional
symptoms.8 9 Crushell et al10 explored parental attitudes to
pain in children with severe FAP. Among 28 children with FAP, What investigations are useful in children with (presumed)
they found that there was higher parental rate of acceptance FAP in the absence of alarm features or red flags?
Investigations have a low yield in FAP, but significant family
pressure can develop in the search for an organic cause. General
Table 1 Rome IV classification of functional gastrointestinal Medical Council guidance recommends fully informing fami-
disorders: children and adolescents lies regarding a proposed investigation strategy. Of children
H1. Functional nausea and vomiting Features of all functional
presenting with abdominal pain, 90%–94% do not have organic
disorders gastrointestinal pain diagnoses pathology after a full range of investigations including endos-
copy.4 19 For clinicians, the breadth of possible rare diagnoses is
H1a. Cyclic vomiting syndrome. ►► Should occur at least four times per
month.
wide, but investigating a common complaint presents resource
H1b. Functional nausea and functional
►► Should be present for at least 2 challenges and more invasive investigations may have sequelae.
vomiting.
months. A ‘one-­ stop’ approach is preferable to a multi-­ staged and
H1c. Rumination syndrome.
►► Some loss of daily function. prolonged approach to investigation.
H1d. Aerophagia. ►► Can be made based on selective In a community study assessing children with chronic abdom-
H2. Functional abdominal pain negative testing rather than inal pain compared with healthy controls, 157 of 200 were
disorders diagnosis of exclusion.
tested for stool ova, cysts and parasites and blood inflamma-
H2a. Functional dyspepsia. ►► Can be associated with other
somatic symptoms such as fatigue/ tory markers: white cell count, erythrocyte sedimentation rate
H2b. Irritable bowel syndrome.
limb pain. (ESR) and haemoglobin. Of 15 children with stools positive
H2c. Abdominal migraine.
►► The severity of symptoms (eg, pain) for parasites, there was no difference in rates in symptomatic
H2d. Functional abdominal pain-­not is not related to the likelihood of children (6 of 97, 6%) and asymptomatic carriage (9 of 70,
otherwise specified. disease, but other red flags are more 13%; p=0.28).20 Coeliac disease is present in around 1% of the
likely to point towards disease.
school-­age population, but symptoms can be relatively minor.21
H3. Functional defaecation disorders
If there are specific dietary triggers, a food allergy panel can
H3a. Functional constipation. be considered, but will only identify IgE-­mediated food sensi-
H3b. Non-­retentive faecal incontinence. tivities.22 Inflammatory markers (ESR/C-­ reactive protein/
Adapted from Hyams et al.5 platelets) are elevated in 75% of patients with inflammatory
2 Andrews ET, et al. Arch Dis Child 2020;0:1–7. doi:10.1136/archdischild-2020-318825

bowel disease. Faecal calprotectin also falls into this group of
readily available and non-­invasive tests and improves pick-­up
for inflammatory bowel disease.23 Helicobacter pylori stool
antigen is useful in patients with dyspeptic symptoms and has
high sensitivity and specificity, but there is no impact on FAP
disease course.24 25 Urine dip is important in those children
with urinary symptoms.
Ultrasonography is a relatively cheap and non-­invasive inves-
tigative tool without radiation exposure and provides some
parental reassurance; however, in children with no alarm symp-
toms, abnormalities are found in less than 1% of cases.26 A signif-
icant proportion of positive ultrasound (USS) findings may not
be related to the abdominal pain and are incidental findings.27
Endoscopy is required if symptoms or investigations point to
an underlying pathology, but carries risks relating to the proce-
dure and anaesthetic. Reports of endoscopic abnormalities in
children with FAP are varied (between 9.7% and 56%), with
reporting significantly limited by small sample size bias as well as
the generalisability of findings.27 28 Minor oesophagitis, gastritis
or duodenitis may not be relevant to the underlying pathology or
treatment and are not necessarily markers of clinically significant
disease.29
The dual effects of testing in giving reassurance to families and
excluding an organic cause for the pain are of equal importance.
Clinical bottom line: A one-­stop targeted investigation panel
including a coeliac screen, inflammatory markers and faecal
calprotectin has clinical utility, although investigations have a
pick-­up rate of less than 5%–10%.
Which commonly used treatments have evidence of efficacy?
Dietary restriction
A significant number of patients with FAP develop or have
increased symptoms after eating and therefore attribute some
blame to dietary components. A Finnish population study found
that nearly half of mothers of children aged 10–11 years with
recurrent gastrointestinal symptoms felt these were related to
dairy and avoided milk products.30 However, other studies
noted that lactose intolerance is not increased in children with
FAP,31 and lactose reduction and avoiding milk products do not
reduce FAP symptoms.22 32
Dietary restriction of gluten among individuals without coeliac
disease has increased recently.33 Gluten intolerance and coeliac
disease are relatively rare in children with recurrent abdominal
pain.30 A higher proportion of children with coeliac disease than
controls remain symptomatic even after a prolonged period
on a gluten-­free diet and histological improvement, suggesting
that removal of a definite trigger may not necessarily help the
symptoms.34 It is also notable that non-­coeliac gluten and wheat
sensitivities are relatively new, but distinct, clinical phenomena
adding to the diagnostic challenge.33 35
Introducing a low fermentable oligosaccharides, disac-
charides, monosaccharides and polyols (FODMAP) diet has
attracted significant interest. A low FODMAP diet restricts the
FODMAP group of carbohydrates followed by graded reintro-
duction and personalisation.36 One study looked at the effect
of a low FODMAP diet on 33 children with IBS and found a
significant decrease in abdominal pain episodes.37 Despite this,
evidence is largely lacking for FODMAP diets being effective in
children with FAP.38
Clinical bottom line: Food exclusions (such as dairy or gluten)
should be limited and reintroduction attempted to ascertain effi-
cacy. There is not enough evidence to routinely recommend a
FODMAP diet in children.
Andrews ET, et al. Arch Dis Child 2020;0:1–7. doi:10.1136/archdischild-2020-318825
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Probiotics
There has been a rise in interest in the gut microbiota, including
its role in FAP.39 The mechanism of the effect of probiotics on
FAP is poorly understood and evidence for their use is limited.15
Hypotheses include the abnormal microbiota activating the
mucosal innate immune responses, increasing epithelial perme-
ability and dysregulating the enteric nervous system.39 Small
intestine bacterial overgrowth and altered intestinal micro-
biota are also implicated.39 A double-­blind, placebo-­controlled,
randomised controlled trial (RCT) was conducted where 141
children with IBS or FAP were given Lactobacillus rhamnosus
GG.40 A sustained and significant effect on the frequency and
severity of pain symptoms reporting in this group that persisted
8 weeks after treatment cessation was found.40 Other studies
have assessed differing strains of L. reuteri and found significant
improvement.41 42 However, a recent systematic review could
not find a significant clinical effect of probiotics in children with
FAP.15
Clinical bottom line: There is evidence for a trial of probi-
otics, although no superiority of a probiotic strain has been
demonstrated.
Pharmacological options
Fibre
It is common for parents of children with FAP to ascribe some
pain to food intolerances, low-­fibre diet or unhealthy food.8
While low dietary fibre is associated with recurrent abdominal
pain in children,43 there are few data supporting increasing fibre
content in the diet. Only one study on 60 children using partially
by copyright.
hydrolysed guar gum showed some improvement of pain inten-
sity as compared with placebo at 4 and 8 weeks, but was not
statistically significant.44 Current evidence suggests additional
fibre is unlikely to be helpful in children with FAP unless it coex-
ists with constipation.22
Antispasmodics
A significant number of trials of peppermint oil have been
undertaken in adults with IBS, with efficacy likely due to its
menthol component blocking calcium channels. One RCT of
120 children with FAP showed peppermint oil was significantly
superior to lactol (Bacillus coagulans + fructooligosaccharide)
and placebo in decreasing pain in the peppermint oil group.45
However, generally evidence for the efficacy of peppermint oil
in children with FAP is lacking, with only one other small RCT
showing evidence of effect, with the recommendation that any
treatment should be a short trial only.46
Mebeverine acts on smooth muscle cells.47 In a single, placebo-­
controlled RCT in children with FAP, mebeverine caused a (statis-
tically non-­significant) decrease in pain.48 With such limited data
it is difficult to recommend mebeverine further.
There is little evidence on Buscopan (hyoscine butylbro-
mide) for children with FAP, with one study of 236 children
showing improved pain scores in an emergency department
setting for children attending with presumed FAP.49 Of note,
paracetamol produced the same reduction in pain on a 100 mm
Visual Analogue Scale of approximately 30 mm.49 Long-­term use
should be tempered against the associated anticholinergic side
effects and lack of data for clinical efficacy in children.50
Antidepressants remain an area of interest for research into
FAP.51 There are limited data on amitriptyline in FAP in children,
with the few studies available showing minor or no significant
difference.13 51 52 Despite this, tricyclic use in FAP is relatively
common (as many as 62% of paediatric gastroenterologists in
3
4
Table 2 Table of evidence for treatment of children with FAP
Treatment or intervention
Parental distraction
Parental acceptance of biopsychosocial
model
Cognitive–behavioural therapy
Measurement of rectal hypersensitivity
Probiotics
Probiotics (Lactobacillus rhamnosus GG)
Hypnotherapy
Lactose elimination
Lactose and fructose malabsorption
Association with coeliac disease and FAP
Low FODMAP diet
Probiotic L. reuteri DSM 17938
Probiotic L. reuteri
Impact of social modelling
Andrews ET, et al. Arch Dis Child 2020;0:1–7. doi:10.1136/archdischild-2020-318825
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Arch Dis Child: first published as 10.1136/archdischild-2020-318825 on 9 March 2020. Downloaded from http://adc.bmj.com/ on March 10, 2020 at Columbia University Libraries. Protected
Study design
Randomised controlled trial.
Records review and structured
telephone interview.
Prospective, longitudinal,
randomised to social learning
and CBT inperson, by phone
and education/support
condition by phone.
Rectal barostat exam and
gastrointestinal symptom
severity assessed by validated
questionnaires.
Systematic review.
Randomised, double-­blind,
placebo-­controlled.
Randomised controlled trial.
Cohort study.
Double-­blinded, placebo-­
controlled provocation.
Prospective study.
Double-­blind, crossover trial.
Randomised, double-­blind,
placebo-­controlled trial.
Randomised, double-­blind,
placebo-­controlled trial.
Parental interviews.
Review
Author, year n Accuracy measure Outcome reviewed Limitations and comments
9
Walker et al, 2006 223 β(210)=0.69 (p<0.001) (reflecting Pre and post self-­report measure of Parents randomised to attention, distraction
children randomised to parental attention gastrointestinal symptoms and measure of or no instruction.
expressed significantly more symptom child utterances.
complaints).
Crushell et al, 200310 28 OR=47.67 (95% CI 3.56 to 1511.6) of Likelihood of parents attributing pain  
parents attributing pain to a psychological to psychological cause in a group of
cause if child had recovered. recovered or ongoing FAP.
Levy et al, 201762 316 No difference in abdominal pain Primary outcome of pain, secondary No significant difference in primary
index (p=0.24) but decreased outcomes of parental solicitousness, pain outcome.
parent solicitousness (p≤0.01) and beliefs, catastrophising and child-­reported
catastrophising (p≤0.01). coping.
Castilloux et al, 200814 47 Median rectal sensitivity pressure=26 Rectal sensitivity pressure and number  
(89% hypersensitive). and % who had rectal sensitivity pressure
≤30.8 mm Hg.
Wegh et al, 201815 Abdominal PF and PI. Unable to show a significant clinical effect  
with FAP.
Francavilla et al, 201040 141 PF at weeks 1–4=4.2 vs 3 (p=0.1), at Number and intensity of episodes of pain, No significant difference in treatment
weeks 13–20=1.1 vs 1.4 (p=0.6). and percentage of treatment success. success, some non-­sustained difference in
Intensity of pain: 4.1 vs 4.1 (p=0.6), at PF and PI.
weeks 13–20, 2.2 vs 3.0 (p=0.05).
Vlieger et al, 200718 53 Remission at 12 months 25% (control) vs Pain intensity, pain frequency and clinical  
85% (hypnotherapy) (p≤0.001). PI and PF remission at 6 months and 1 year.
significantly improved in the hypnotherapy
group (p<0.002).
Lebenthalet al, 198131 164 31% of FAP group were lactase-­deficient Lactose elimination for 12 months in non-­ Similar lactose absorption rates in both
vs 26.4% of controls. absorbers leads to 40% elimination of pain children with FAP and controls and no
vs 42% absorbers with normal diet. improvement with elimination diet.
Gijsbers et al, 201232 220 Lactose malabsorption found in 57 of 210 Pain disappeared on elimination in 24 of Double-­blind provocation was negative for
and fructose in 79 of 121. 38 patients with lactose malabsorption all children.
and 32 of 49 with fructose malabsorption.
Turco et al, 201134 156 28% of patients with coeliac disease vs 28% vs 8.9% (p=0.008); OR 3.97, 95% CI Children with coeliac disease on a GF diet
8.9% of controls fulfilled the Rome III FGID 1.40 to 11.21. have a higher prevalence of FGID than
criteria. controls.
Chumpitazi et al, 201537 33     Children with IBS, not FAP.
Weizman et al, 201641 101 Decreased PF (1.9 vs 3.6, p≤0.02) and PI Children with FAP randomised to L. reuteri Sustained and significant reduction in PF
(4.3 vs 7.2, p<0.01). DSMM 17938 or placebo. and PI with L. reuteri.
Romano et al, 201442 60 PI significantly lower in L. reuteri group at No difference between groups for PF at Both groups had reduction of PF over time.
4 and 8 weeks. any time.
van Tilburg, 201762 15 Identified worries around fear of a disease, Categorisation of parental ideas and Supports reasoning behind parental
desire for diagnosis and treatment, and worries. reinforcement of illness behaviour.
feelings of helplessness.
Continued
 Table 2 Continued
Treatment or intervention Study design Author, year n Accuracy measure Outcome reviewed Limitations and comments
Low dietary fibre Cross-­sectional study with Paulo et al, 200643 82 Total fibre in RAP with and without Difference in grams/day of total fibre Low dietary fibre intake more prevalent in
control group. constipation and control, 18.2, 16.6 and (also soluble and insoluble fibre) between children with recurrent abdominal pain.
23.7 for total fibre (p≤0.001). groups.
Supplemental dietary fibre (partially Randomised, double-­blind, Romano et al, 201344 60 Wong-­Baker pain score at 8 weeks of Included analysis of change in symptoms No significant symptom improvement for
hydrolysed guar gum) placebo-­controlled trial. intervention and placebo, 1.63 vs 2.05 for IBS. FAP.
(p≥0.05).
Peppermint oil vs Synbiotic Lactol (Bacillus Randomised, placebo-­ Asgarshirazi et al, 120 PI and frequency both improved in both PI and PF decrease in peppermint oil, Statistically significant improvements in PI
coagulans + fructooligosaccharide) controlled trial. 201545 intervention arms. 5.23–3.11 (p=0.0001), 4.24–2 (p=0.0001), and PF for control group also.
lactol 5.75–3.93 (p=0.0001), 4.83–2.14
(p=0.0001).
Mebeverine Randomised, double-­blind Pourmoghaddas et al, 115 Treatment response of mebeverine vs Change in pain scale. No statistically Dose: mebeverine 135 mg two times per
placebo-­controlled trial. 201448 control, 54.5% and 39.5% at week 4 significant change at week 4 or 12. day.
(p=0.117).

Andrews ET, et al. Arch Dis Child 2020;0:1–7. doi:10.1136/archdischild-2020-318825

Amitriptyline Multicentre, placebo-­controlled Saps et al, 200952 90 63% in treatment arm and 57.5% in Pain relief good in 38% of the treatment Both amitriptyline and placebo had
trial. placebo felt better (p=0.63). arm and 35% of placebo (p=0.83). therapeutic effect, no statistical difference.
Hypnotherapy Long-­term follow-­up of Vlieger et al, 201263 49 68% of hypnotherapy vs 20% of standard Questionnaire-­based follow-­up. At mean follow-­up of 4.8 years,
randomised controlled trial. care in remission (p=0.005). hypnotherapy still superior.
Guided imagery Randomised controlled trial Weydert et al 200664 22 Decrease in days with pain, guided Decrease in days with missed activities, Sustained effect at 2 months of follow-­up.
(guided imagery vs breathing imagery vs breathing techniques, 67% vs guided imagery vs breathing techniques,
exercises). 21% (p=0.05) at 1 month. 85% vs 15% (p=0.02) at 1 month.
Cognitive–behavioural therapy Randomised controlled trial. van der Veek et al, 104 At 1 year, 60% of CBT vs 56.4% of Nearly all secondary outcomes improved in CBT as effective as intensive medical care.
201356 intensive medical care significantly both groups.
improved or recovered (p=0.47).
Acceptance-­based interoceptive exposure Single intervention trial. Zucker et al, 201757 24 Distress reduction from 0.53 to 0.20 Parents’ rating of child pain reduction from Parental rating of child pain and distress
(p=0.0004). 1.43 to 0.64 (p=0.0003). used as primary outcomes.
Yoga therapy Randomised controlled trial. Korterink et al, 201659 69 Yoga vs standard medical care treatment Significant reduction in PI (p≤0.01) and PF Treatment response only significantly
response, 58% vs 29% (p=0.01) at 1 year. (p≤0.01) at 1 year. different at 1 year.
Neurostimulation Randomised, double-­blind, Kovacic et al, 201760 115 Worst pain score at 3 weeks, 5.0 and 7.0   Sustained improvement for pain-­related
sham-­controlled trial. for intervention vs sham (p≤0.0001). symptoms.
CBT, cognitive–behavioural therapy; FAP, functional abdominal pain; FGID, functional gastrointestinal disorder; FODMAP, fermentable oligosaccharides, disaccharides, monosaccharides and polyols diet; GF, gluten-­free; IBS, irritable bowel
syndrome; PF, pain frequency; PI, pain intensity; RAP, recurrent abdominal pain.
Review

5
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Arch Dis Child: first published as 10.1136/archdischild-2020-318825 on 9 March 2020. Downloaded from http://adc.bmj.com/ on March 10, 2020 at Columbia University Libraries. Protected
 Review
North America reported prescribing tricyclics for FGIDs), with
speculative mechanisms including increased sleep and reduction
of visceral hypersensitivity.51
The use of H2 antagonists and laxatives in children with FAP is
affected by case definition, with a bigger evidence base in gastro-­
oesophageal reflux and constipation, respectively: one small
RCT with famotidine compared with placebo (n=25 children
with functional dyspepsia) showed subjective improvements but
no objective reduction in pain scores.38 53 There are no trials of
laxatives available in children with FAP.
Clinical bottom line: There are not enough data to recom-
mend mebeverine or antidepressants (despite antidepressants
commonly being used in some areas). Short trials of peppermint
oil or antispasmodics may be considered, in addition to gaining
parental acceptance of the functional nature of the abdominal
pain. Features of dyspepsia or constipation may benefit from
trials of treatment (H2 antagonists/proton pump inhibitors or
laxatives, respectively).
Psychological therapy
Hypnotherapy and guided imagery have been the subject of
several studies. One systematic review of hypnotherapy in
children with FAP or IBS found three RCTs comparing hypno-
therapy either by qualified therapists or on audio CD with stan-
dard medical care,54 finding pain levels in the hypnotherapy
group were significantly lower than in the control group and
that improvement was maintained.54 Potential underlying
mechanisms of action include reduction of physiological and
psychological stress, decreasing colonic motility, and decreasing
visceral hypersensitivity.54 A recent Cochrane review including
four RCTs of hypnotherapy commented that hypnotherapy has
some beneficial effects in reducing short-­term pain, and long-­
term outcome data are limited to only one study.55 The data
supporting hypnotherapy therefore appear better than most
other available therapies.
Psychological interventions, including CBT, have been
assessed given the role of anxiety in children with FAP. A 2017
Cochrane review found very low quality evidence on the bene-
ficial effects of CBT, which was absent at medium-­term or long-­
term follow-­up.55 Another study compared CBT with six visits
to a paediatrician for children with FAP and found no significant
difference.56 Acceptance-­based interoceptive exposure for young
children with FAP has also been investigated.57
Other therapies
Yoga therapy in children with FAP aims to reduce anxiety,
improve tone and increase feelings of well-­being.58 Korterink
et al59 looked at yoga therapy in 69 children aged 8–18 with
‘abdominal pain-­ related’ FGIDs, noting significant improve-
ments in pain intensity scoring and school absence but not in
pain frequency or quality of life. A recent Cochrane review
concluded that there was no robust evidence for the effective-
ness of yoga therapy.55
Neurostimulation devices delivering percutaneous electrical
nerve field stimulation have also been studied in one RCT on
115 children. Using the Pain Frequency-­ Severity-­
Duration
Scale, these devices improved pain tolerance and significantly
improved worst pain (2.1, 95% CI 1.3 o 2.9, p<0.0001) and
composite pain scores (11.4, 95% CI 6.6 to 16.3, p<0.0001),
with a median follow-­up of 9.2 weeks.60
Conclusions
The response and specific attention that a child receives when
complaining of pain should be considered when assessing
6 Andrews ET, et al. Arch Dis Child 2020;0:1–7. doi:10.1136/archdischild-2020-318825
Arch Dis Child: first published as 10.1136/archdischild-2020-318825 on 9 March 2020. Downloaded from http://adc.bmj.com/ on March 10, 2020 at Columbia University Libraries. Protected
children with suspected FAP. Detailed explanations, appropriate
to the understanding of the family and the patient help accep-
tance of a biopsychosocial model (where a physical or psycholog-
ical trigger is affected by the child’s developing personality and
influenced by parental and peer feedback). The evidence that
stress plays a significant role in symptoms can help the clinician
initiate a wider conversation about triggers.2 Methods of coping
include prioritising distraction in families or CBT/hypnotherapy,
which again stresses that this condition should not be looked at
through a disease model alone.9 54 It is however important to
consider the distress and impact that FAP can have on children
and families. Investigations should be limited to a ‘one-­stop’
approach where possible and should routinely include blood
tests and faecal calprotectin, with the acknowledgement that
further investigation is likely to be of low yield in the absence of
new or alarm features. A firm diagnosis of a FAP disorder should
be made where diagnostic criteria are fulfilled. In terms of treat-
ment options, these are limited, as outlined in table 2; however,
probiotics and peppermint oil are emerging in trials as potential
therapeutic strategies, within the reassurance of treating a func-
tional condition.61
Funding The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-­for-­profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement Data sharing not applicable as no data sets were
generated and/or analysed for this study. All data relevant to the study are included
in the article or uploaded as supplementary information.
by copyright.
ORCID iDs
Edward Thomas Andrews http://​orcid.​org/​0000-​0001-​9781-​8041
R Mark Beattie http://​orcid.​org/​0000-​0003-​4721-​0577
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