Case Presentation : The Integrative Care of a child with - PowerPoint Presentation

1. Case Presentation: The Integrative Care of a child with functional abdominal painPatricia Estrada, MSN(c), RNIntegrative HealthFall 2018

2. ObjectivesAfter attending this case presentation, participants will be able to:Analyze a case presentation of a 7 year old child with Recurrent Abdominal Pain (RAP) Describe the theories for the pathophysiology associated with RAPIdentify the Rome IV criteria for recurrent abdominal pain, specifically functional abdominal pain (FAP)Evaluate treatment options based on high-quality research

3. Present the Patient:DemographicsA 7-year-old female pediatric patient presents with daily generalized abdominal pain lasting for 30 minutes to 2 hours, beginning 2 years ago around the start of kindergarten, occurring most often before and after school. She also has daily mild headaches usually occurring after school that have been happening for about the same amount of time.

4. Present the Patient:HistoryA well child with no other significant medical, trauma, birth, or psychiatric history. Up to date on vax. Lives with mother, father, younger sister. Family History negative for bowel or abdominal problemspositive migraine headaches: mother and maternal grandfatherpositive for anxiety: mother, maternal aunt, maternal grandfatherpositive for depression: maternal aunt

5. Present the Patient:Medications and CAMList of Medications & SupplementsGummy multivitamin (2 times per week)Acetaminophen 325mg PO (~2 times/week)Probiotics (refuses due to increased bowel movements at school)Use of CAM including lifestyle modificationCool and warm compress (ineffective)Diet changes: eats moderately healthy, school lunches, lactose free milk but eats cheese and ice cream, unresponsive to gluten free

6. Present the Patient:Review Of Systems (subjective)Abdominal pain, does not always finish meal due to stomach pain. Daily formed BM.Headaches daily to 3 days per week, occasionally prevents participation in sports, ADLs, activitiesNo weight curve changes, no nausea, vomiting, diarrhea, fever, bloody stools or rashes; No head injury or trauma, vertigo, weakness, or confusion; Normal full eye exam, normal vision; No depressive symptoms, normal sleep habitsOccasional, once weekly, bilateral leg pain, aching in the evening, resolved after sleep

7. ObjectiveGeneral: healthy appearing, well groomed, bright affect, laughing and playing, thoughtfulNeurologic: A&O, coherent, speech clear. CN 2-12 intact, motor movements coordinated, no weaknessEyes: Visual acuity intact, lid margins clear, conjunctiva pink, sclera anicteric, PERRLA. Abdomen: Abdomen flat, normo-active BS present. No localized tenderness on abdominal palpation. No masses. Liver border not palpableFSBS 99, UA wnl, CBC wnl, ESR wnl, XR neg

8. AssessmentRecurrent abdominal painFurther separated as Functional (nonorganic) Abdominal Pain (FAP) Established by presenting clinical features based on the Rome IV criteria. Abdominal pain at least 4 times per month (for at least two months)Not associated with eating or mensesDoes not meet criteria for abdominal migraine, functional dyspepsia, irritable bowel syndrome

9. Presentation of the Clinical ProblemEpidemiology (for RAP)Up to 5% of primary care visits, worldwide affects 13.5% of childrenDivisions of RAPFunctional abdominal pain: 53.8%Irritable bowel syndrome: 38.5%Functional dyspepsia: 7.7%

10. Etiology/PathophysiologyMany pathophysiologic pathways have been suggested including altered gastrointestinal microbiota, mucosa or motility, altered immune system or central nervous system function, or visceral hypersensitivity (Newlove-Delgado et al., 2017). Psychosocial factors have also been implicated in the symptom cluster. Presentation of the Clinical Problem

11. Presentation of the Clinical ProblemSigns and SymptomsPrimary symptom is abdominal painOther symptoms are also associated with RAP in children including headache, anxiety and emotional disorders, trouble sleeping and limb pain. The abdominal pain may cause “some loss of daily functioning” and many children loose time spent in schooling or other activities (Rasquin et al., 2006).

12. Treatments and Evidence: ProbioticsImplication of gastrointestinal microbiota in the pathophysiology RAP. Probiotics contain living micro-organisms which alter the normal microbiota of the intestinal tract. A systematic review found improvement in pain, a reduction in pain frequency and decrease in pain intensity in children who were taking probiotics (Newlove-Delgado et al., 2017). Presentation of the Clinical Problem

13. Presentation of the Clinical ProblemTreatments and Evidence: PeppermintPeppermint has been shown to reduce abdominal pain in children with IBS (Rakel, 2017) and may help reduce pain in FAP through it’s antispasmotic effects.

14. Presentation of the Clinical ProblemTreatments and Evidence: HypnotherapyHypnotherapy including guided imagery has shown some success for reduced pain frequency and intensity in children with RAP (Abbott et al., 2017). Guided imagery activates portions of the brain and can create a response that may facilitate pain reduction through relaxation and pain relief suggestion (Rakel, 2017).

15. Presentation of the Clinical ProblemTreatments and Evidence: BiofeedbackBiofeedback has been shown to be a good tool to use to show the effect of mindful relaxation on the physical body (Rakel, 2017). One exploratory study showed improvement for children using biofeedback showing that more research should be done as this may be a supportive treatment for children with RAP (Stern, Guiles, & Gevirtz, 2014).

16. Return to the Patient: The Plan What did you try? What didn't work?Probiotics: for 7 days, the patient refused to continue treatment as they made her have BMs at school

17. Return to the Patient: The Plan Current PlanTime probiotics in the evening or re-trial probiotics while on a school breakTrial of peppermint (enteric-coated capsule) 200mg (one capsule) PO three times per dayFuture PlanTherapy: the patient has an initial therapy appointment with a counselor in one month to discuss options for guided imagery, biofeedback or hypnotherapy

18. SummaryA 7-year-old female with functional abdominal pain classified by the Rome IV criteria, with associated symptoms of headache and leg pain, has pain that occasionally interrupts daily activities. She has no alarm symptoms or other bowel function problems. She has trialed probiotics and is willing to try them again. She will also try peppermint and has an upcoming appointment with a child therapist to introduce guided imagery, hypnotherapy or biofeedback.

19. ConclusionsMore high quality research is needed on the causes and treatments for Recurrent Abdominal Pain in children. I would especially like to see research in the area of acupuncture which has shown to be effective in other pain pathways. Untreated RAP in children has been shown to put patients at risk for other pain syndromes as well as depression in adulthood so must be treated effectively.

20. ReferencesAbbott, R. A., Martin, A. E., Newlove-Delgado, T. V., Bethel, A., Thompson-Coon, J., Whear, R., & Logan, S. (2017). Psychosocial interventions for recurrent abdominal pain in childhood. The Cochrane Database of Systematic Reviews, 1, CD010971. https://doi.org/10.1002/14651858.CD010971.pub2Newlove-Delgado, T. V., Martin, A. E., Abbott, R. A., Bethel, A., Thompson-Coon, J., Whear, R., & Logan, S. (2017). Dietary interventions for recurrent abdominal pain in childhood. The Cochrane Database of Systematic Reviews, 3, CD010972. https://doi.org/10.1002/14651858.CD010972.pub2Rakel, D. (2017). Integrative Medicine. Elsevier Health Sciences.Rasquin, A., Di Lorenzo, C., Forbes, D., Guiraldes, E., Hyams, J. S., Staiano, A., & Walker, L. S. (2006). Childhood functional gastrointestinal disorders: child/adolescent. Gastroenterology, 130(5), 1527–1537. https://doi.org/10.1053/j.gastro.2005.08.063Reust, C. E., & Williams, A. (2018). Recurrent Abdominal Pain in Children. American Family Physician, 97(12), 785–793.Stern, M., Guiles, R., & Gevirtz, R. (2014). HRV Biofeedback for Pediatric Irritable Bowel Syndrome and Functional Abdominal Pain: A Clinical Replication Series. Applied Psychophysiology & Biofeedback, 39(3/4), 287–291.