Discuss with the patient and family what is known and not known about functional RAP, and encourage them to ask questions. This is an opportunity for you to instill hope and cultivate positive expectations, but avoid promising cure. Discuss the gut-brain connection and relevance of visceral hyperalgesia, including serotonin’s potential roles in RAP pathogenesis.
Partners in care. Collaborative treatment increases the likelihood of success. Discuss the importance of a therapeutic partnership, and clarify any areas of disagreement with the diagnosis or treatment plan.
Clearly delineate your roles and responsibilities and those of the patient, family, and other health care team members. Poor communication is pediatricians’ most common complaint about psychiatrists.14 Good interdisciplinary communication decreases the chance that treatment strategies will be duplicated, diluted, or misinterpreted.
Consolidate medical care with a single clinician—often the primary care physician—based on discussions with the patient, family, and health care team. The coordinating clinician can mediate between the school and family when tensions develop over poor attendance or requests for special treatment. It is often useful for this clinician to spell out:
- what constitutes a legitimate medical excuse for school absence
- who will legitimize excuses.
All parties should understand that the school will view an unexcused absence as truancy and act appropriately.
Diet and lifestyle. Encourage the patient to maintain a regular schedule and a healthy diet. Specific dietary interventions have not been proven effective, despite speculation that lack of dietary fiber or lactose intolerance might cause RAP.15,16 Also encourage adequate sleep and regular exercise.
Medication and psychotherapy
Because no strong evidence-based guidelines address pediatric RAP intervention, family preferences usually guide initial treatment decisions. This highlights the importance of good communication and a therapeutic partnership among the clinician, family, and patient.
Antispasmodics, acid reducers, and antidepressants are commonly prescribed for RAP, though none are well-supported in the literature and no controlled studies have gauged medication’s impact on psychiatric comorbidity.16
Antidepressants. Selective serotonin reuptake inhibitors (SSRIs) might help relieve RAP symptoms, but the evidence is inconclusive. SSRIs are considered potentially beneficial in RAP because they may help communicate nociceptive information between the gut and brain and mediate visceral hyperalgesia.
SSRIs at first may increase serotonin at the synapse, which one might assume would to worsen abdominal symptoms. However, ongoing SSRI use could “down-regulate” postsynaptic 5-HT3 receptors and desensitize postsynaptic cells to the effects of local serotonin.
Our group recently conducted a 12-week open trial of citalopram for functional pediatric RAP.17 The 25 participants received 10 mg/d the first week, then 20 mg/d thereafter if tolerated. At week 4, nonresponders and partial responders who were tolerating the medication began receiving 40 mg/d.
Table 3
SSRI daily dosing for pediatric RAP
| Drug | Starting dosage* | Target dosage† | Maximum dosage‡ |
|---|---|---|---|
| Citalopram | 10 mg | 20 mg | 40 to 60 mg |
| Escitalopram | 5 mg | 10 mg | 20 to 30 mg |
| Fluoxetine | 10 mg | 20 mg | 40 mg |
| Fluvoxamine | 50 mg | 100 mg | 300 mg |
| Sertraline | 25 mg | 50 mg | 200 mg |
| * First 3 to 7 days. | |||
| † If patient tolerates starting dosage, increase to target dosage. | |||
| ‡ If patient does not respond to target dosage in 2 to 3 weeks, consider increasing the dosage. | |||
At trial’s end, more than two-thirds of participants were taking 40 mg/d. We rated 21 of 25 patients (84%) as “much improved” or “very much improved,” using the Clinical Global Impression-Improvement scale. Abdominal pain, anxiety, depression, other somatic symptoms, and functional impairment all improved significantly during treatment. Suicidal thoughts diminished progressively from baseline, and no patient reported suicidal thinking at study’s end. Citalopram was generally well tolerated.
With SSRI treatment, start at a low dosage for 3 to 7 days (Table 3). If tolerated, increase to a typical therapeutic dosage. If symptoms fail to respond after 2 or 3 weeks, consider a higher dosage. A short course of an oral benzodiazepine (such as clonazepam, 0.25 mg bid) during the first weeks of SSRI treatment sometimes helps particularly anxious patients or those whose pain appears closely associated with anxiety or “stress.”
Pediatric gastroenterologists often prescribe a low-dose tricyclic antidepressant as first-line therapy, but we discourage this. TCAs lack efficacy in pediatric depression and pose a greater risk of side effects and safety concerns than SSRIs.18
Other agents have been tried for RAP-associated conditions:
Famotidine, a histamine type 2 receptor blocker, may reduce pain in children with dyspepsia and RAP.19
Peppermint oil reduced abdominal pain in one study of children with IBS but had little effect on other symptoms.20
Medications such as alosetron and tegaserod that interrupt serotonergic neurotransmission in the gut have shown benefit in adults with IBS but have not been studied in children.
Psychotherapy. A few small studies suggest that cognitive-behavioral therapies (CBT) are helpful in RAP, but CBT may be difficult to deliver in medical settings.21,22 A simplified “rehabilitative” approach that incorporates CBT principles involves having the clinician and patient view RAP as a challenge to be overcome, rather than a burden to be endured. Such an approach emphasizes the child’s fundamental strength and adaptability rather than vulnerabilities.