Recurrent abdominal pain (RAP) in children describes recurring abdominal pain without an organic cause. RAP in children is defined as abdominal pain which occurs at least four times a month over a period of two months or more, which is severe enough to limit a child's activities and which, after appropriate evaluation, cannot be attributed to another medical condition. It presents commonly in general practice and it causes a great deal of school absence and considerable anxiety.

RAP is believed to be a functional gut-brain interaction disorder (FGID) caused by altered feedback mechanisms between the gut and central pain pathways. There are several defined RAP patterns in children, of which pediatric irritable bowel syndrome (IBS) is the most common [1,2]. The original definition of RAP, published in 1958, including both organic and functional pain [3].

The prevalence of RAP affects 10-20% of school-aged children worldwide [4]. 3-8% of children with this pattern of pain have a causative organic pathology (and are excluded from the Rome definition of RAP). RAP occurs most commonly between ages 5 and 14 years. It is uncommon in children under 5 years of age. Boys are more commonly affected than Girls (relative prevalence 1.5). Prevalence in girls has led to suggestions that levels of sex hormones might play a role.

Ovarian hormones can modulate both visceral pain perception and the susceptibility to stress. There is an association between obesity and RAP [5]. There is an association between stress and RAP. Children with RAP are more likely to have experienced events such as deaths of family members, domestic violence, harsh punishment from parents, parental job loss and economic stress, hospitalization, and bullying. Children with a history of cow's milk protein hypersensitivity or abdominal surgery have an increased prevalence of FGIDs years later [6].

The pathophysiology involves dysregulation of visceral nerve pathways, leading to visceral hyperalgesia. Infective, inflammatory or psychological triggers may initiate this sensitization [7,8]. The onset of pediatric IBS frequently follows an episode of acute gastrointestinal inflammation (infectious or non-infectious) [9]. RAP is additionally affected by temperament and by family and school environments (the biopsychosocial model).

The patients who did not satisfy the above criteria were considered to have Non-organic RAP and were compared with an equal number of age and sex-matched controls, that comprised of children attending the Paediatric Outpatient Department

Statistical Analysis: All the data obtained were presented in percentages using Microsoft excel.

Out of 120 patients of RAP, sex distribution is unequal with male predominance (64.1%) and less female (35.3%) (Table 1).

Table-1: Distribution of gender.

Table-2: Distribution of age group.

Although in this study, age group was in the following order by decreasing 7-10 years old (43.3%), followed by 4-6 years old (36.3%) and 11-14 years old (20%) (Table 2).

Table-3: Characteristics: Organic RAP Versus Non-organic RAP.

Severe pain can see in 8 ORAP and 36 NORAP, and mild pain in 1 ORAP and 31 NORAP. Whereas, the site of pain especially in the periumbilical region in ORAP was 6 and 49 NORAP children, and lower abdomen pain in organic ORAP was 2 and 9 NORAP children. Moreover, 2 months duration of disease in ORAP was 13 and 5 NORAP children, and more than 12 months in ORAP was 1 and 91 NORAP children. In addition, the presence of bloating in ORAP was 5 and 34 NORAP children, and the absence of bloating in ORAP was 9 and 72 NORAP children. The presence of early satiety in ORAP was 6 and 35 NORAP children, and the absence of satiety in ORAP was 8 and 71 NORAP children.

Furthermore, in our results loss of appetite in ORAP was 9 and 72 NORAP children. The presence of nausea in ORAP was 4 and 23 NORAP children. The presence of vomiting in ORAP was 3 and 21 NORAP children. The deification of loose stools in ORAP was 6 and 22 NORAP children. Interference with sleep in ORAP was 10 and 43 NORAP children, and non-interference with sleep in ORAP was 4 and 63 NORAP children. Headache in ORAP was 4 and 21 NORAP children. School absenteeism in ORAP was 10 and 43 NORAP children. Photophobia was seen in ORAP was 11 and 84 NORAP children. Finally, pallor was seen in ORAP was 4 and 22 NORAP children.

Pediatric RAP is a significant and prevalent problem, which can have a massive impact on a child's well-being, hitting school attendance, mood and their perception of their own health and fitness. If an over-prolonged search for the organic disease is pursued at the expense of thorough assessment, engagement, explanation, and review, the problem can become increasingly difficult for a parent, patient, and doctor [13].

However, with careful history and examination, clear explanation and follow-up and a commitment from parent and child to stop the condition limiting normal activities, good results are obtained for children without referral, drugs or extensive testing [14].

In the current study, teenagers with RAP had significantly lower quality of life (QoL) in all four domains; physical, emotional, social and school functioning. This lower QoL scores were significant in irritable bowel syndrome (IBS), abdominal migraine (AM) and functional abdominal pain (FAP).

Similar to the current study, in the previous study conducted in children aged 5 to 15 years with recurrent abdominal pain, the only symptom associated with healthcare consultation was vomiting [25]. In contrast to this, other previous studies conducted in younger children have shown significant associations between health care consultation and age of onset, severity, frequency and duration of pain episodes, school absenteeism, sleep interruption and disruption of normal activity [26-28]. It is parents who take the children to see a doctor. Unlike younger children, teenagers are reluctant to discuss their bodily symptoms with their parents. Some of the parents may not be aware of these symptoms in their children. That may be a reason for the lack of association between healthcare consultation and some symptoms. However, a symptom like vomiting and bloating are visible to the parents and readily recognized. They are also alarming symptoms, especially in teenage girls in reproductive age. So those with bloating and vomiting are more likely to be taken to a doctor. In addition, due to variation in the perception of symptoms, the impact on the quality of life is more likely to influence healthcare consultation than the exact severity. In agreement with this, the current study found significantly lower scores for school functioning and physical functioning domains of QoL in healthcare consulters than in non-consulters.

The pathophysiology of RAP is thought to involve abnormalities in the enteric nervous system – a complex nervous system that envelops the entire gastrointestinal (GI) tract. Dysregulation of this brain-gut communication plays an important role in the pathogenesis of RAP [29]. Factors such as visceral hypersensitivity, altered intestinal motility, and visceral hyperalgesia could disrupt the brain-gut interaction and explain the cause of pain.

Changes in intraluminal pressure and mucosal inflammatory processes secondary to infections, allergies or primary inflammatory diseases may cause sensitization of afferent nerves associated with the onset of hyperalgesia [30]. At the molecular level, brain and gut peptides, mucosal immunology, inflammation and alterations in the bacterial flora of the gut probably provide the translational basis for GI symptom generation [31].

Many modalities of treatment such as dietary interventions, probiotics, pharmacological therapy, psychological support, and alternative medicine have been suggested, studied and screened.

1. The current study has a smaller sample size, the large sample size is required for answering the question related to the ORAP and NORAP.
2. As the current study is a single-center study, large multicentre studies will help in the assessment of improved outcome which will be beneficial for our society.
3. The duration of study on a long term basis will help in more additional therapeutic benefits along with our primary outcome.

This study has assessed organic and non-organic RAP in Badnapur teenagers aged 4 to 13 years with abdominal pain predominant functional gastrointestinal diseases. The main symptoms associated with healthcare consultation were abdominal bloating and vomiting. The health-related quality of life was an important determinant of healthcare consultation, more than the severity of individual symptoms. Our results suggest that an organic cause such as giardiasis is the commonest cause of RAP. However, both organic and non-organic factors need to be managed simultaneously for proper management of RAP.

Studies should target specific phenotypes of symptoms rather than RAP in general. Children should be categorized as per the Rome III criteria into separate disorders as there is a difference in etiology and response to therapy. Start a symptom diary. Explore with the family non-pharmaceutical pain management strategies such as muscle relaxation, art, movement, and imagery. Plan an early follow up appointment to review investigation results, diary entries, and pain management. The treatment goal is to ease pain and enable the child to function normally. Treatment should be individualized. Explanation and reassurance are all that is required in many cases. Referral to a child psychologist is recommended when anxiety or mood disorder is suspected and when symptoms are disabling and have not responded to first-line strategies. Note that children <8 years of age cognitively have difficulty understanding that feelings can cause physical symptoms.