RAPS is prevalent in about 10 % of school-aged children in general, and up to 28 % of girls between 9 and 12 years of age [4, 7] (Fig. 4.1).

The age of onset of pains peaks for both boys and girls at about 5 years. The incidence peaks again for girls around pubescence (9–12 years of age) [7, 8] (Fig. 4.2).

The quality and location of pains. Attempts have been made to characterize Recurrent Abdominal Pain Syndrome as having either dyspeptic or irritable bowel patterns [3]. Dyspeptic symptoms consist of intermittent pain or burning localized to the epigastrium, not related to the urge to pass stool or flatus and not fulfilling criteria for biliary tract disorders [3]. Irritable Bowel Syndrome (IBS) pains are related to defecation and/or are associated with the change in the frequency and/or form of stools [3]. Whereas the typical location of dyspeptic symptoms is the epigastrium, the pain of Irritable Bowel Syndrome is typically mid- or lower abdominal.

A review of the charts of 100 of my patients referred for RAPS, chosen at random, revealed that the descriptions of pain quality conformed to dyspepsia in 12 patients, IBS in 38 patients, and both Dyspeptic and Irritable Bowel in 15 patients. Notably, 30 patients could not characterize their pain. (There was insufficient data for five patients.) The mid-abdominal location predominated in both children whose symptoms conformed to the Dyspeptic and to the Irritable Bowel patterns as well as children whose pains had features of both. Therefore, the pain of RAPS is typically mid-abdominal, less frequently epigastric [8] and therefore cannot be unequivocally classified as either dyspepsia or IBS in many patients.

Durations of pains: pain episodes last minutes to hours [7, 8].

Intensity of pains: Pain intensity is often so mild that the child’s activity and appearance are unchanged; or the pain can be severe enough to cause the child to lie down, become pale and temporarily incapacitated. It is rare for an episode of pain to occur during the consultative visit.

Precipitants of pains: About two-thirds of patients report that their pains are precipitated by heightened emotional states, respiratory infections, or eating [7, 8].

Temporal pattern of abdominal pain complaints: Pain complaints may be heard at any time during waking hours, especially before leaving for school, around dinner time, or at bedtime [8]. A key diagnostic feature of RAPS is that, regardless of how often or severe the pain is while the child is awake, it seldom interrupts the child’s sleep [8, 9]. When parents are asked whether their child has ever been awakened from sleep by his or her pain, most answer “no.” When the answer is “yes,” I try to assess whether the nocturnal awakenings with alleged abdominal pain occur as often, much less often, or only rarely compared with the frequency with pain complaints during waking hours. Most indicate that nocturnal awakenings are rare, e.g., 0–4 times during the preceding few months in a child who might complain of pain during waking hours on an almost daily basis. In the few cases in which nocturnal awakenings are said to be frequent, I ask for a description of the child’s behavior when awake and the nature and rapidity of his or her response to being comforted (e.g., being allowed into the parents’ bed or being accompanied back to his or her own bed by mother.) If there is behavioral evidence of emotional upset, such as a nightmare or other emotional cause for interrupted sleep, then it is likely that the child is using “tummy ache” as a code word for emotional distress. Children have difficulty distinguishing bodily pain from emotional distress and may use a familiar complaint that evokes parental concern to elicit the comforting they may truly need for relief of their emotional distress. If, on the other hand, the frequency of nocturnal pain complaints and the child’s response to parental comforting suggests actual bodily pain, then an organic cause for the complaint is more likely and must be investigated.

Family history: A history of functional gastrointestinal symptoms is eight times as common in first degree relatives of children with RAPS compared with relatives of the children who do not have RAPS [7].

Review of systems: Functional, autonomically mediated symptoms (such as a tendency to vomit easily, susceptibility to motion sickness, pallor without anemia, orthostatic lightheadedness) are common in patients with RAPS [7].

Physical findings: Physical exam is negative for signs of disease. There may be mild tenderness without guarding in one or both lower quadrants of the abdomen [8]. Deep palpation of the left iliac fossa may reveal a firm “slippery rope”-like segment of colon, which may contain lumps of segmented stool.

Ordinarily, management of RAPS is accomplished by eliciting a comprehensive history in the context of good rapport, performance of a gentle but through physical examination, a urinalysis and the conveyance of three essential communications (which were presented in the Introductory Chapter’s section, “The Form and Content of Consultations,” and are reiterated here as applied to RAPS). These communications aim to satisfy the cogitative and emotional needs created by the child’s illness (see Table 4.1).

If all American children with RAPS consulted pediatric gastroenterologists one time within 1 year, then each physician would have to see an estimated 30 RAP patients per day, 250 days per year. The implausibility of his scenario begs the question: what prompts a referral to a sub-specialist for evaluation of this functional disorder? [10, 11]

I reviewed the psychosocial histories of 50 of my recurrent abdominal pain patients, selected at random, and was somewhat surprised to find that, in 44 of them, the consultations were prompted by new or increased concerns about symptoms that had been present and less problematic long before the current exacerbation. It is not accurate or helpful to label RAPS as a psychogenic disorder (i.e., “due to psychic, mental or emotional factors and not to detectable organic or somatic factors” [12]). However, if the goal of the clinician extends beyond merely diagnosing and prescribing for the presenting complaints, but also includes getting at the origins of the complaints and what prompted the referral, then that understanding is achieved by bringing the psychosocial elements of the illness to light. It takes an investment of the clinician’s time because, as the documentarian Ken Burns has said, “Meaning accrues in some sort of duration.” Grasping the meaning of a patient’s illness empowers the clinician to help the patient overcome it.

It is likely that physicians are seldom consulted for most children with recurrent stomach aches; they are effectively managed without having to be referred to a pediatric sub-specialist [11]. What motivates those who are referred? They are referred because they are perceived by parents, pediatricians or both as having symptoms that are especially acute, incapacitating, refractory to first-line management and are therefore more worrisome. It turns out that, in most such patients, the perceived acuity of the child’s symptoms, i.e., the factor that makes the symptoms require urgent attention now, not later, is not just the abdominal pain per se, but the fear created by unrecognized emotional distress caused by recent or remote events in the lives of family members, particularly the parents, in whom the child’s sense of secure stability resides [10, 13].

The more comprehensive biopsychosocial method of evaluating a child referred for RAPS requires 1½–3 h of time for the initial consultation. Is this an indulgent waste of time? The following case exemplifies how comprehensive evaluations employing this model of clinical practice can resolve what I’ll refer to as a functional abdominal pain crisis.

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