NEW YORK—Children with chronic recurrent abdominal pain (CRAP) often respond well to a combination of simple herbal therapies, dietary changes, and biofeedback, reported Joy Weidert, MD, at the third annual Pediatric Integrative Medicine Conference.

“The present standard of conventional care for this common problem is usually to tell the parents there is no “organic” cause, and that the child will outgrow it,” said Dr. Weidert, director of the Integrative Pain Management program at Children’s Mercy Hospital, Kansas City. “In many cases, we don’t do anything, just give them a pat on the head. That’s not much of a standard of care.”

The other conventional tactic is to hit these kids with lots of drugs, including antispasmodics, anticholinergics, beta blockers, H2 blockers, or tricyclic antidepressants, very few of which have been tested in children or have any demonstrated efficacy for abdominal pain. “I see kids who’ve been on some of these meds for two years or more. I really wonder what that’s doing to them.”

CRAP is an appropriate acronym for this condition; kids with abdominal pain problems have an average of 26 school absences per year versus only 5 for kids without the condition; 50% or more show signs of depression, and 30% go on to have digestive disorders including irritable bowel in adulthood. In other words, many do not “outgrow it.”

Dr. Weidert takes an integrative approach to managing kids with CRAP, often combining herbal medicines with massage therapy, probiotics, elimination of problem foods, and mind-body techniques like guided imagery.

Basic Labwork

Before proceeding in that direction, though, she typically orders a complete blood count, urinalysis, sedimentation rate, and fecal occult blood test, to rule out anemia, infection, urinary tract infection, diabetes or other serious diseases. “The tests are almost always negative, but I get them if only to reassure the parents.”

She added that it is important to befriend the parents. “Ask about their fears. A lot of times they are scared their child has cancer, because they heard somewhere about a kid with abdominal pain who had a horrible tumor. I try to reassure them that just like a headache is rarely a brain tumor, abdominal pain is rarely cancer.”

She also recommended IgG testing for delayed food sensitivities. “It can be very useful to identify the foods that trigger high IgG antibody responses, and to try and reduce them in the child’s diet. In many cases you can markedly reduce the intensity and frequency of pain by eliminating problem foods.

Herbal Help for Abdominal Pain

Physicians have several herbal allies to help children with CRAP, including chamomile, enterically coated peppermint, ginger, slippery elm, and deglycyrrhizinated licorice. All are safe for use in kids, and give significant relief.

Chamomile (Matricaria recutita): This calming antispasmodic herb is Dr. Weidert’s first-call botanical for kids with abdominal pain. It contains volatile oils that promote relaxation of GI smooth muscle, as well as flavonoids that bind to similar receptors as benzodiazepines, but without being heavily sedating or inducing dependence. Give a cup of chamomile tea or a standardized liquid extract 3–4 times per day. “It is very safe, comforting and helpful. The only contraindication is in kids with allergies to ragweed, daisies or related plants.”

Peppermint (Mentha piperita): Another antispasmodic, peppermint oil contains compounds that act like calcium channel blockers and inhibit smooth muscle contraction. It is especially good for intestinal problems like irritable bowel. Because peppermint can be somewhat aggravating to upper GI mucosa, it is best to use enterically coated tablets or capsules; give them 2–3 times daily, depending on symptom frequency and intensity.

Ginger (Zingiber officinale): Rich in volatile oils and aromatic ketones, ginger can dilate small blood vessels, giving it a gentle but powerful antispasmodic effect. It also down-regulates inflammation, and quells nausea, making it a good choice for kids with upper GI problems. There are many liquid, tablet or capsule formulations of ginger, but the fresh root can also be grated, boiled with water and taken as a tea. It is especially tasty when sweetened with honey or maple syrup. “The only contraindication for ginger is that it may relax the esophageal sphincter in some people, predisposing to reflux,” said Dr. Weidert.

Slippery Elm (Ulmus rubra): The powdered inner bark of this tree is excellent for coating the upper GI mucosa and stimulating mucus production, making it an ideal herb for kids with ulcers, reflux or other upper GI problems. It can be taken as a tea or a liquid extract. Parents who like working with herbs may want to buy the powdered bark and make tea for their children: Simply mix I part bark powder to 8 parts water, and give the child 1–2 ml of the solution 3–4 times per day.

Deglycyrrhizinated licorice (Glycyrrhiza glabra): Licorice has been used as medicine for over 3,000 years. Among its many effects, it can inhibit phospholipase A, reducing inflammation. It also coats irritated mucosal tissue, making it a good remedy for kids with irritable bowel-like syndromes. Because glycyrrhizin, a key component of licorice, can trigger adverse effects like hyperkalemia, headache, hypertension and edema, most commercial preparations are deglycyrrhizinated, which is important when giving this herb to kids. Good commercial DGL preparations are actually safer than licorice candies.

Probiotics

In many kids with CRAP, the intestinal flora is highly disordered. Probiotics can be extremely helpful, particularly if the child has been exposed to antibiotics.

There are many probiotics available on the market today, containing various strains of bacteria like Acidophilus, Lactobacillus, and Bifidobacterium, or probiotic yeasts like Saccharomyces boulardii. There is considerable debate over which is the “best” species or best strain.

In Dr. Weidert’s experience, the main thing is to make sure effective doses of the probiotic organisms reach the child’s intestine. “You need to get at least 1 billion live colony forming units down there, several times per day.” Probiotics are seldom a quick fix symptom-reliever, though, and parents need to understand it can take several weeks of daily dosing to re-establish healthy gut ecology.

Massage, Biofeedback, and Guided Imagery

“We have a licensed massage therapist at our clinic, and we send a lot of kids with abdominal pain to her. She can really get things moving in a lot of them,” said Dr. Weidert. In general, massage helps a child to relax, and when specifically focused on the abdominal area, it can improve GI motility, making it a useful modality for kids with constipation problems.

Kids are also receptive to self-hypnosis and guided imagery. At Dr. Weidert’s clinic, they teach children progressive muscle relaxation and belly breathing exercises, then progress to imaging exercises where the kids imagine their favorite safest places, and to go there when they feel pain.

In some cases, they are taught to imagine what the pain looks like, and then imagine effective solutions to the pain.” Imagery is effective in children as young as 4 or 5, so long as they have the necessary language skills.

Good sleep is extremely important. Lack of sleep heightens perception of pain, and of course, it interferes with school performance. Teach parents how to help their kids sleep better, by limiting pre-bedtime TV, cutting out sugar, soda, and other stimulants. A bath with Epsom salts, and a cup of chamomile tea make a great sleep-inducing combination.

It is very important to encourage these kids and their families to maintain a normal and healthy daily activity level, even if they do have belly pain. The parents should not let their child off the hook for chores, homework or other responsibilities. “You don’t want the kid to make a connection between the pain and all sorts of special treatment, or you end up reinforcing the illness.”