Review of childhood pain highlights the role of negative stress.

AIM: Recurrent pain of unknown origin is a major problem in children. The aim of the present review was to examine the hypothesis of negative stress as an aetiology of recurrent pain from different aspects. METHODS AND RESULTS: Epidemiological studies, clinical experience and hormonal data give support for such a hypothesis. Negative stress as a tentative aetiology for recurrent pain is reviewed. Stress, muscular tension, the startle reaction and its tentative relation to pain is illuminated. Deviations of hormonal secretion supporting a stress aetiology are mentioned. The role of central sensitisation for recurrent pain is discussed. Possible aetiological implications of recurrent pain as a local symptom or a general disorder are presented. Brain changes due to stress are shortly reviewed. Stress and pain in the clinic are highlighted. The importance of biological, psychological and social factors, as well as genetic elements, is discussed. CONCLUSION: Stress elicits neurobiological mechanisms. They may lead to many neurophysiological deviances. Increase of muscle tension and neuromuscular excitability and enhanced startle reaction may be of importance for recurring pain. The identification of stress as a primary cause of recurrent pain can have huge implications for understanding signs and treatment in clinical practice.

Children with chronic stress-induced recurrent muscle pain have enhanced startle reaction.

BACKGROUND: Children with recurrent pain of negative chronic stress origin from different locations have a characteristic pattern of tender points in the temporal, trapezoid, great pectoral and abdominal muscles. We tested the hypothesis that the startle reaction is activated in these children and that some of the startle-activated muscles are related to the tender point pattern and the recurrent pain. METHODS: In children/adolescents, aged 10-17 years, 19 with recurrent psychosomatic pain (PAIN) and 23 controls (CON) we measured and analysed resting activity and acoustic startle response with electromyography (EMG) for the muscles involved in the pattern of tender points and also the lumbar erector spinae. RESULTS: The PAIN group showed higher resting activity and higher acoustic startle response values than the CON group for all six muscles together regarding the mean amplitude in the initial 200 ms, and during the burst of activity, and longer burst duration and shorter burst latency. For PAIN versus CON, all separate muscles showed generally higher values of EMG amplitudes and burst durations, and shorter latencies for the burst onset in all measures; with significance or strong trends for several parameters and muscles. CONCLUSION: For the first time in children with recurrent psychosomatic pain, increased resting activity and potentiated startle response were demonstrated in the muscles involved in the stress tender point pattern. SIGNIFICANCE: This study demonstrates in adolescents how recurrent pain of negative stress origin from the head, stomach, back and chest is related to increased startle reaction and increased muscular tension in these regions. This study contributes to the understanding of the mechanisms underlying the global burden of recurrent pain.

A new method for the treatment of recurrent abdominal pain of prolonged negative stress origin.

OBJECTIVE: To test the hypothesis that psychological treatment given in combination with somatic treatment can relieve recurrent abdominal pain (RAP) of psychosomatic origin in childhood. STUDY DESIGN: Stomach Pain Clinic Group A, comprising 25 children receiving a combination of psychological treatment and physiotherapy given by two different persons and Stomach Pain Clinic Group B, comprising 23 children receiving physiotherapy only, were constituted in a randomized manner. Stomach Pain Clinic Group C, including 35 children receiving an integrated combination of psychological treatment and somatic treatment given by the same person was also constituted, as well as a reference group. Treatment outcome was measured by calculating a pain score and tender points (TP) score at inclusion and after 1 year. RESULTS: The pain score after 1 year improved significantly in all four groups. Stomach Pain Clinic Groups A and B did not show any significant difference, but Stomach Pain Clinic C had a significantly better outcome than Stomach Pain Clinic Group B. Stomach Pain Clinic Groups A and C had a significant decrease in the TP score after 1 year. Pain scores and TP scores calculated for all Stomach Pain Clinic groups correlated significantly at follow-up after 1 year. CONCLUSION: For children with psychosomatic RAP, a special method for integrated psychological and somatic treatment is probably effective. The results have to be confirmed in a randomized controlled study. These children have a special pattern of TPs related to their disorder, which diminishes with improvement in the disorder.

Diurnal salivary cortisol concentration in school-aged children: increased morning cortisol concentration and total cortisol concentration negatively correlated to body mass index in children with recurrent abdominal pain of psychosomatic origin.

INTRODUCTION: The sampling method for salivary cortisol is sensitive, specific and pain-free. Our knowledge about cortisol concentration in saliva and plasma in school-aged children is sparse and contradictory. AIM: To estimate diurnal variation in salivary cortisol concentration in children with and without psychosomatic recurrent abdominal pain (RAP), and to compare groups and relate the concentrations to age, sex, puberty, body mass index (BMI), allergy, headache and ethnicity. CHILDREN AND METHOD: Saliva was collected in 'Salivette' tubes from 159 healthy girls and 147 healthy boys, aged 5-15 years, and from 25 girls and 6 boys, aged 6-18 years, with RAP of psychosomatic origin, at 08.00 h, 13.00 h and 20.00 h. Saliva was analysed using a commercial RIA-cortisol kit. RESULTS: The median concentrations in healthy girls and boys were 8.8/8.3 nmol/l at 08.00 h, 5.5/5.3 nmol/l at 13.00 h, and 2.1/2.3 nmol/l at 20.00 h, respectively. Cortisol concentrations differed between 6-7 year-old and 9 year-old children (higher in the former). Age-matched post-menarcheal girls had higher cortisol concentrations in the evening, 2.2 vs 1.7 nmol/l (p = 0.03). The results were independent of BMI, headache and allergy. In the RAP group, diurnal cortisol concentrations in girls/boys at the different time-points were 14.8/12.9, 5.2/5.8, and 2.4/2.7 nmol/l, respectively, and were negatively correlated to BMI. Total secretion of cortisol was higher than in healthy children. Cortisol concentration was independent of allergy, headache and ethnicity, CONCLUSION: In healthy children, salivary cortisol concentration was dependent on time, age and menarche. In children with RAP of psychosomatic origin, morning and total secretion of cortisol were significantly higher than in healthy children and negatively correlated to BMI.

One hundred cases of recurrent abdominal pain in children: diagnostic procedures and criteria for a psychosomatic diagnosis.

AIMS: To highlight the diagnostic difficulties involved in elucidating the aetiology of recurrent abdominal pain and to evaluate the use of special premises and criteria for the diagnosis of psychosomatic pain. METHODS: The study included 100 consecutive cases of recurrent abdominal pain in 6 to 15 y-old children who were evaluated at a special paediatric clinic for recurrent abdominal pain and who were followed for at least one year. The investigation included a semi-structured questionnaire, laboratory investigations based on clinical data and diagnoses based on defined criteria. Three premises and seven criteria, based on the assumption that chronic negative stress can cause recurrent pain, were used for the diagnosis of psychosomatic pain. RESULTS: When the presented premises and criteria were employed for the diagnosis of psychosomatic pain, nearly half of the cases (48%) of recurrent abdominal pain could be explained. An organic or possibly organic diagnosis was found in 25% of the cases. Fourteen children had a possible psychosomatic diagnosis and in 9 cases no known diagnosis could be reached. CONCLUSION: The presented premises and criteria for the diagnosis of psychosomatic pain can be helpful when diagnosing recurrent abdominal pain, but further validation is needed. According to these criteria, a psychosomatic diagnosis was common in this series, accounting for nearly half of the cases. A medical diagnosis was evident in a quarter of the cases.

Recurrent abdominal pain. A world-wide problem of organic, functional and psychosomatic aetiology.

This spring, Acta Paediatrica is publishing five original articles underlining the importance of recurrent abdominal pain (RAP) and illustrating the scientific and diagnostic difficulties involved in understanding it. Our knowledge of organic causes is increasing with improved instruments for investigation, including 24-h pH monitoring and endoscopy, but the difficulty in how to link findings of organic abnormalities conclusively to the symptom RAP has to be further elaborated and discussed. There is an old belief that many cases of RAP have a psychogenic aetiology. Psychometric tests in past decades, however, have not supported this belief, but if the reaction primarily is one of negative stress, than we should be looking for negative stress reactions, not for psychopathology. RAP of psychosomatic origin is not just a matter of excluding organic disease, but a diagnosis that must be built on firm positive diagnostic criteria, criteria that have not yet been elaborated for a broader public.

Long-chain polyunsaturated fatty acids in human milk and brain growth during early infancy.

Long-chain polyunsaturated fatty acids are essential for growth and development, and their crucial role in the development of the central nervous system and in retinal function has been the subject of many studies. As the balance between n-6 and n-3 fatty acids has to be optimal, their concentrations in the milk given to infants who are exclusively breastfed is of major importance. In this study, the composition of fatty acids in mothers' milk and the growth rate of the infant brain were analysed. Nineteen mother-term infant pairs from Stockholm, Sweden, were studied from birth to 1 mo and 3 mo of age, during which time the infants were breastfed exclusively. The dietary intake of the mothers was calculated and found to concur with the recommended daily dietary allowances of Swedish lactating women as regards energy, protein, fat and carbohydrates. The amounts of linoleic acid and alpha-linolenic acid in the diet were similar to those reported for European and North American women. The ratio between arachidonic acid (AA) and docosahexaenoic acid (DHA) in the milk from Swedish mothers is approximately the same as in the brain of infants, and was found to be positively correlated with the rate of gain of the occipito-frontal head circumference and of the calculated brain weight at 1 mo (p < 0.01) and 3 mo (p < 0.01) of age, respectively. However, further studies are needed to establish the exact requirements of AA and DHA for optimal growth and development during early infancy in exclusively breastfed infants.

One-week treatment with omeprazole, clarithromycin, and metronidazole in children with Helicobacter pylori infection.

BACKGROUND: The efficacy of a 1-week "triple therapy" in children with Helicobacter pylori gastritis and recurrent abdominal pain was studied. The effect of treatment was also studied in correlation to recurrent abdominal pain. METHODS: Thirty-two children with recurrent abdominal pain were investigated with H. pylori serology, 13C-urea breath test, and endoscopy. Gastric biopsy specimens were analyzed with a rapid urease test and histopathology. H. pylori-positive children were treated with omeprazole, clarithromycin, and metronidazole for 7 days. The same treatment was repeated for 2 weeks if a urea breath test produced positive results 1 month after the treatment period. If the test results were still positive after treatment, a second endoscopy was performed with culture. RESULTS: Twenty-eight (87.5%) children were urea breath test-negative at follow-up 4 weeks (range, 4-15) after treatment. Another child became H. pylori-negative after a second treatment course. Two of the three children who were still positive after the two treatment periods, showed resistance to metronidazole and clarithromycin. CONCLUSIONS: One-week therapy with omeprazole, clarithromycin and metronidazole is an effective treatment in children with H. pylori infection. Bacterial resistance to clarithromycin and metronidazole must be monitored if treatment fails.

Psychosomatic pain in children: a psychomuscular tension reaction?

Although recurrent psychosomatic pain is a common paediatric condition, our understanding of it is still limited. In this article, the clinical picture is presented and the concept of psychosomatic pain is discussed. Some recent scientific data are presented including a controlled blind study of pain pressure thresholds showing significantly reduced mean values over common pain areas in a group of children with psychosomatic pain. According to another study, these children also have significantly reduced concentrations of the hypothalamic hormone oxytocin and cortisol. With these data as a point of departure, a model for psychosomatic pain reaction is outlined in which stress is assumed to induce muscular tension, in turn triggering the nociceptive process. In this psychosomatic reaction, the hypothalamus is believed to have a central regulatory function.

Age-related decrease in plasma levels of gastrin, cholecystokinin and somatostatin.

Newborn babies have higher concentrations of gastrointestinal hormones than adults. The aim of the present study was to investigate the relationship between age and plasma levels of the three peptides gastrin, cholecystokinin and somatostatin in healthy children aged 1-15 years. Gastrin, cholecystokinin and somatostatin concentrations were twice as high at 1-2 years of age compared with children older than 10 years. Significant negative correlations between age and hormone concentrations were established. It is suggested that these age-dependent differences are related to the growth rate and relative energy consumption during the early years of life.

[Psychosomatic pain in children--a psychomuscular stress reaction?]. / Psykosomatisk smärta hos barn--en psykomuskulär spänningsreaktion?

Recurrent psychosomatic pain is a common paediatric problem. Our knowledge in this respect remains incomplete, and there is a manifest need of research in this field. A model of a psychosomatic process with pain as an important symptom is presented in the article, where the hypothalamus and the muscular system are important components. The nociceptive progress has its origin in muscular tension, and is regulated and modified in the central nervous system. Both local and central sensitisation is assumed to be crucially involved in the pain process. The importance of excluding the possibility of organic disease is emphasised, and some guidelines for diagnosis and treatment are given.

Depressed concentrations of oxytocin and cortisol in children with recurrent abdominal pain of non-organic origin.

The purpose of the present study was to measure plasma concentrations of oxytocin, cortisol and prolactin in children with recurrent abdominal pain of non-organic origin (RAP). Forty children with RAP and 34 controls, matched for age and sex, participated in the study. A blood sample was collected after an overnight fast in association with clinical examinations. Oxytocin, cortisol and prolactin levels were determined by radioimmunoassay (RIA). Oxytocin and cortisol concentrations in the children with RAP were found to be significantly reduced compared with those of the controls (approximately 24 versus 63 pmol/l for oxytocin and 160 versus 300 nmol/l for cortisol, respectively). The low oxytocin and cortisol levels persisted at a second examination 3 months later. No significant differences in the prolactin levels were observed between RAP and controls.

Elevated cholecystokinin concentrations in plasma in children with recurrent abdominal pain.

The objective of the present study was to measure plasma concentrations of the gastrointestinal hormones gastrin, somatostatin and cholecystokinin in plasma of children with recurrent abdominal pain, since these hormones affect gastrointestinal function. Forty-four children (7-16 years old) with recurrent abdominal pain and 36 control children (matched for age and sex) participated in the study. In a blood sample collected after an overnight fast, gastrin, somatostatin and cholecystokinin concentrations were measured by radioimmunoassay. The children with recurrent abdominal pain had higher plasma cholecystokinin levels (p < 0.001) than the controls. Whether or not this aberration is related to the clinical symptoms of children with recurrent abdominal pain remains to be established.

The pressure pain threshold (PPT) of certain muscles in children suffering from recurrent abdominal pain of non-organic origin. An algometric study.

The origin of recurrent abdominal pain of "non-organic origin" is believed to be psychogenic in most cases. But the pathogenesis of the pain itself is unknown. To test the hypothesis that recurrent abdominal pain of non-organic origin is related to increased pain sensitivity in the myofascial elements of the abdominal wall itself, an investigation of pain pressure threshold of the abdominal wall, close to the umbilicus, was carried out. Altogether 140 children in the fourth school grade, approximately 11 years old, were tested for pressure pain threshold. Two groups were constituted: one without pain symptoms (no recurrent abdominal pain, chest pains or headache (n = 50)) and one with recurrent abdominal pain (n = 49). The pressure pain threshold differed significantly (p < 0.0001). To support the hypothesis that recurrent abdominal pain is a part phenomenon of a specific pattern of muscular tension and tenderness, the pressure pain threshold was tested in five other muscles, with significant results.

The covariation of common psychosomatic symptoms among children from socio-economically differing residential areas. An epidemiological study.

Psychosomatic symptoms among children are believed to be commonplace. In this investigation by questionnaire, 47% of 1333 schoolchildren reported one or several symptoms, such as recurrent abdominal pain, headache, chest pains, loss of appetite and disturbances in bowel function. Coexistence of such symptoms was considerable and if a child had one of these, the probability that it would have one or more other symptoms was significantly increased. This correlation may strengthen both the suspicion that these symptoms are often psychosomatic and the idea that they have common CNS origin. There were appreciable differences in the frequency of the symptoms, between children at the more socially stable schools and schools with social problems. In the latter, the frequencies of symptoms differed between Swedish and immigrant children, which was not the case in the more socially stable schools.

Preliminary findings on increased muscle tension and tenderness, and recurrent abdominal pain in children. A clinical study.

Recurrent abdominal pain of "non-organic origin" is a common pediatric problem. In most instances it is related to psychological factors. The origin of the pain itself, however, is still unknown. In this study, we question whether or not the complaint could have a muscular origin. In this clinical study of recurrent abdominal pain of probable "psychosomatic origin", all 27 children had tense and tender abdominal muscles, which was not the case in a control group. The children with recurrent abdominal pain also had a typical pattern of muscular tension and tenderness in other muscles. These children often have tension headache, "tension" chest pains and also more general symptoms such as loss of appetite and disturbed bowel function.