05 October 2004

Gastrointestinal pain in children

The NYT has an article up on unexplained chronic gastrointestinal pain in children. It is, of course, non-technical enough that it probably isn't really useful, but underscores again one of my hobbyhorses: Things like anxiety, depression, and broader psychological responses, aren't as easily separable from pain as most think. As you all now know, I believe that many such factors ought to be regarded as intrinsic properties of the pain.

Nothing in this article argues for that point, but it does raise one (admittedly philosophically lame) consideration for it: Part of the stigma of receiving psychological/pscyhatric treatment for pain may lie in the thought that the sufferer is somehow deficient or abnormal in her response to pain. If we take such responses to partially constitute the pain (that is, to be part of what the pain is), then the perceived deficiency is incoherent.* It plausibly assumes that we cannot be criticized for our pains --like kidneys they are parts of us but not under our control. But if the 'response' partially constitutes the pain, then the response cannot be open to criticism.

Anyway, enough about me, here's a bit of the article

New approaches to treating pain - including cognitive behavioral therapy; alternative treatments like relaxation techniques and massage therapy; and antidepressants - are already being used in adults, but they have not been widely adopted for children, in part because only a handful of small studies support such use.

In recent years, however, experts have begun to understand more about the connections between the brain and the gut, a relationship that is reflected in popular expressions like "a gut-wrenching experience" or "having butterflies in your stomach."

The gastrointestinal tract is awash in nerve cells and neurotransmitters. About 95 percent of the body's neurotransmitter serotonin is in the intestinal tract. Stress, nervousness, fear and other emotions often play out their own drama in the gut. In children with abdominal pain, the intestinal tract becomes hypersensitive to stimuli, with the slightest bit of gas, for instance, sending a flood of pain signals to the brain

The problem appears to be a mismatch in signaling between the brain and the gut, said Dr. Lonnie Zeltzer, director of the Pediatric Pain Program at the David Geffen School of Medicine at the University of California, Los Angeles. "If you have ongoing pain, you can develop abnormal pain pathways, so that the volume of pain signaling is being turned up and up," Dr. Zeltzer said.

What causes the hypersensitivity is not completely understood, but experts believe that it is often set off by a stomach virus or an infection

"It's not uncommon that a family will get viral gastroenteritis, the whole family gets better except the child," said Dr. Zeltzer, whose book, "Conquering Your Child's Chronic Pain: A Pediatrician's Guide for Reclaiming a Normal Childhood," will be published by HarperResource in January. "The pain system is turned on and stays on."

"It's not uncommon that a family will get viral gastroenteritis, the whole family gets better except the child," said Dr. Zeltzer, whose book, "Conquering Your Child's Chronic Pain: A Pediatrician's Guide for Reclaiming a Normal Childhood," will be published by HarperResource in January. "The pain system is turned on and stays on."....

As an understanding of the brain-gut connection grows, however, some centers have begun to use techniques like cognitive behavioral therapy, relaxation training, massage therapy and other alternative approaches as a first line of treatment.

The effectiveness of these therapies is still debated, and the number of studies examining their effectiveness in children is very small, experts say. In one study published in the August issue of The Journal of Pediatric Gastroenterology and Nutrition, 18 children ages 8 through 17 who had pain for about a year were taught guided imagery and progressive relaxation.

In four to seven sessions, 89 percent of the children reported a reduction in pain, to an average of two episodes a week, from six, said Dr. Youssef, the lead author of the study. The children had fewer missed school days, and their quality-of-life scores rose significantly.

"Our goal is to help them relax about the pain," Dr. Youssef said. "If you don't worry about the pain, you don't get pain." Link

Btw: I think Dr. Youssef should have said 'If you don't worry about the pain, there is no pain'. Picky, picky, picky.

*I'm overstating the metaphysical point here. Constitution may be too strong a relation for what I have in mind. But that is a subject for another post.

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