This is the 153rd #WILTW
This week my youngest daughter has been suffering from intermittent tummy aches. There is no condition that is more difficult to investigate, diagnose and treat than children’s abdominal pain. I say that as a Paediatrician and a Parent.
There are lots of resources that list the multitude of causes of, and treatments for, abdominal pain. These are important for clinical staff who work with children to understand and apply. However, abdominal pain is hugely context dependent and I have realised there is a fragile balance between being prudent and perturbed, regardless of your knowledge base.
I’d like to suggest four co-dependent factors that are likely to impact on getting to the bottom of the problem and successfully treating it:
I’m a big fan of alliterative lists but in this case it’s important not to see any domain as distinct from the others. All the features impact on each other, sometimes simultaneously, making separating them in some respects almost illogical (but illogical is what I will do)
The Nature of Pain is a challenge in children. I am minded of Dr. Edward Snelson’s wise words.
Internal pain is translated into external distress. The outward display of symptoms can often bear no resemblance to what the observer perceives the pain must feel like. While pain scales can be used to quantify an individual’s particular rating of their own discomfort, the dissonance between an observer’s judgement often invalidates them. This is a huge challenge in paediatric practice where the child, parent and professional may all have substantially different interpretations. It is vital though that the child or young persons perceptions are acknowledged and managed.
This is why the Personality of the Child is important. Differing development, family circumstance and chronic health issues mean that individual age is not a good basis for making judgements of how a child will respond in a given situation. I have seen stoical toddlers to blubbing teenagers and vice-versa. In practice most children can be distracted enough to make confident decisions that the pain is not of a serious nature:
“The easiest way of engaging with a child is to tell them you can guess what they had for breakfast. Feel their tummy and shout out random cereals. If you guess correctly after a couple of goes you are considered a genius, but it’s better if you continually get it wrong as the child thinks they are cleverer that you are. Either way you get a good feel of the tummy..”
Working out how a child, and especially a young person, is interpreting their pain is a challenge and when they are very distressed this is definitely impacted by the Response of the Parents.
Addressing the concerns of agitated and anxious parents is as important as those of the children. In some cases more so. There are times when a treatment will take time to take effect and the observation period is vital to understand the nature of the disease process. Leaving a child who is perceived to be in great distress without adequate explanation instantly breaks trust. Parents provide an analgesic effect themselves when calm and engaged to the child’s needs. Conversely they can unintentionally exacerbate situations as agitation raises stress levels in the whole family.
Understanding, and predicting, the Path of the Illness is clearly important to be able to adequately treat pain in a fashion in which the child or young person responds to and the parents or carers understand. The spasmodic but persistent griping pain of constipation is different from the fluctuating but self-limiting non-specific of mesenteric adenitis; despite the fact on paper the presenting complaint is exactly the same. Children of the same age and same disease entitity may have markedly different ways of expressing their discomfort and parents may have very different approaches to seeking help. Context is key to devising an adequate management plan.
What have I learnt this week? Understanding the interplay of illness, individual and their environment is vital. Whichever side of the parent/professional divide you are on…
What have you learnt this week? #WILTW
Don’t forget the Bubbles Tummy Pain
PEM Playbook Paediatric Pain
FOAM EM RSS Abdominal Pain