Evaluation of guided imagery as treatment for recurrent abdominal pain in children: a randomized controlled trial.

BACKGROUND: Because of the paucity of effective evidence-based therapies for children with recurrent abdominal pain, we evaluated the therapeutic effect of guided imagery, a well-studied self-regulation technique. METHODS: 22 children, aged 5-18 years, were randomized to learn either breathing exercises alone or guided imagery with progressive muscle relaxation. Both groups had 4-weekly sessions with a therapist. Children reported the numbers of days with pain, the pain intensity, and missed activities due to abdominal pain using a daily pain diary collected at baseline and during the intervention. Monthly phone calls to the children reported the number of days with pain and the number of days of missed activities experienced during the month of and month following the intervention. Children with < or = 4 days of pain/month and no missed activities due to pain were defined as being healed. Depression, anxiety, and somatization were measured in both children and parents at baseline. RESULTS: At baseline the children who received guided imagery had more days of pain during the preceding month (23 vs. 14 days, P = 0.04). There were no differences in the intensity of painful episodes or any baseline psychological factors between the two groups. Children who learned guided imagery with progressive muscle relaxation had significantly greater decrease in the number of days with pain than those learning breathing exercises alone after one (67% vs. 21%, P = 0.05), and two (82% vs. 45%, P < 0.01) months and significantly greater decrease in days with missed activities at one (85% vs. 15%, P = 0.02) and two (95% vs. 77%. P = 0.05) months. During the two months of follow-up, more children who had learned guided imagery met the threshold of < or = 4 day of pain each month and no missed activities (RR = 7.3, 95%CI [1.1,48.6]) than children who learned only the breathing exercises. CONCLUSION: The therapeutic efficacy of guided imagery with progressive muscle relaxation found in this study is consistent with our present understanding of the pathophysiology of recurrent abdominal pain in children. Although unfamiliar to many pediatricians, guided imagery is a simple, noninvasive therapy with potential benefit for treating children with RAP.

Effectiveness of gun-safety counseling and a gun lock giveaway in a Hispanic community.

OBJECTIVE: To evaluate the effectiveness of gun-safety counseling, a gun-safety brochure, and a free gun lock in subsequent gun removal and safe storage. METHODS: In a predominantly Hispanic pediatric clinic, gun-owning families were identified and assigned to either an intervention group (gun-safety counseling, gun-safety brochure, and a free gun lock) or a control group (usual anticipatory guidance). Families were resurveyed 1 month later for changes in the proportion of gun owners, changes in frequency of unloaded and locked gun storage, and changes to the use of locked storage. RESULTS: Two hundred six (7.8%) of the 2649 parents initially surveyed kept guns in their households. At follow-up, 16% of the control group removed all guns from their homes as compared with 22% of the intervention group (P = .41). Among the families who received the intervention, 61.6% either removed all guns from their homes or improved their gun storage safety practice in some way. Only 26.9% of the families in the control group showed similar types of improvement (P<.001). In those households still with guns at follow-up, 50.9% of the intervention group had some type of improvement in safe gun storage compared with 12.3% of the control group (P<.001). More specifically, 25.0% in the intervention group improved the frequency of locked storage of guns compared with 4.8% of those in the control group (P = .003). Twenty-six percent of the intervention group improved the use of locked storage compared with 3.1% in the control group (P<.001). CONCLUSIONS: A brief gun-safety counseling session supported with written information along with a gun lock giveaway resulted in significant improvements in safe gun storage behaviors. It did not significantly influence the removal of guns from the home. This study gives support to the recommendations of the American Academy of Pediatrics (Elk Grove Village, Ill) and other professional organizations to discuss gun safety with families and encourages research in this area. It also suggests that providing tools such as gun locks to enable the desired behavior may improve safe storage.

Clinic-based screening for domestic violence: use of a child safety questionnaire.

BACKGROUND: Domestic violence affects many women during their lifetime. Children living in homes where they are or have been exposed to violence are at increased risk for adverse outcomes. The American Academy of Pediatrics, the American Academy of Family Practice, and the American College of Obstetrics/Gynecology have recently joined in recommending routine screening of all families for the presence of domestic violence. We present our experience with an office-based domestic violence screening questionnaire. METHODS: A series of four child safety questionnaires (designed for parents of infant, preschool-age, school-age, and adolescent patients), which included specific questions about domestic violence, was given to all mothers presenting to a university out-patient general pediatric clinic. The questionnaires, offered in both English and Spanish, were reviewed for the presence of domestic violence exposure, usually at the time of the clinic visit. The number of women who reported either current or past exposure to domestic violence as disclosed by this active screening process was compared to the number discovered prior to the use of these questionnaires. RESULTS: Prior to the use of active screening with a child safety questionnaire, five cases of domestic violence were identified in our clinic population of approximately 5000 children over a 3 month period. Active screening of this population with a parent questionnaire resulted in the identification of 69 cases of current domestic violence exposure (2% of those screened) during each of 2 years of screening. Use of the child safety questionnaire was associated with a significantly increased odds of detecting current domestic violence (OR = 3.6, 95% CI [1.4, 9.1], P = 0.007), with 72% [26-84%] of the cases identified being attributable to the use of the questionnaire. Of children screened, 2% were currently exposed to domestic violence, and 13% had been exposed to past domestic violence. Thus a total of 15% of our patient population has been exposed to domestic violence in their homes. CONCLUSION: Children in our clinic population are frequently exposed to domestic violence. Active screening for the presence of current or past domestic violence through the use of a parent questionnaire resulted in a significant increase in our ability to identify such families and provide appropriate referral information.

Methodological challenges to treatment trials for recurrent abdominal pain in children.

BACKGROUND: Studies evaluating the efficacy of treatments for recurrent abdominal pain (RAP) in children have used a wide range of methods, causing difficulty in the comparison of results. An expert panel on functional gastrointestinal disorders recently made recommendations regarding the standardization of study methods for childhood RAP, but many of their recommendations remain untested or lack supportive evidence. METHODS: During completion of a pilot study and randomized controlled trial for childhood RAP, baseline data were collected regarding the child and parent reports of abdominal pain frequency and intensity, type of abdominal pain, missed activities due to abdominal pain, psychological factors for the parent and child, parenting styles, and referral source (pediatric gastroenterologist vs general pediatrician). RESULTS: Children and parent pain reports showed good agreement in children younger than 13 years (weighted kappa, 0.77; 95% confidence interval [CI], 0.71-0.84), but only marginal agreement in children 13 years or older (weighted kappa, 0.37; 95% CI, 0.30-0.45). We found no significant differences in pain characteristics or psychological factors between children referred by pediatric gastroenterologists in a tertiary care center and those referred by community-based primary care pediatricians. However, children with symptoms consistent with nonspecific functional abdominal pain were reported by their parents to have less frequent pain (P=.003) and fewer missed activities (P=.003) than children with symptoms of irritable bowel syndrome or functional dyspepsia. CONCLUSIONS: Subjects referred by gastroenterologists and general pediatricians were similar, but the subtype of functional gastrointestinal disorder might be an important baseline characteristic of subjects in future RAP studies. We suggest that future interventional studies of childhood RAP measure 2 outcomes with pain reports obtained directly from children. Any child with fewer days of pain and missed activities due to pain after therapy would be considered improved, and those with no missed activities and 4 or fewer days of pain per month at follow-up would be considered healed.

Influence of attendance at day care on the common cold from birth through 13 years of age.

OBJECTIVE: To describe trends in the occurrence of the common cold during the first 13 years of life among children who attended different childcare settings early in life. DESIGN: The Tucson Children's Respiratory Study involves 1246 children enrolled at birth and followed up prospectively since May 1980 through October 1984. Children with data regarding day care use during the first 3 years of life were included in this investigation (n = 991). Parents reported the occurrence of frequent (> or = 4) colds during the past year by questionnaire when each child was 2, 3, 6, 8, 11, and 13 years of age. Child care at home (no unrelated children), at small day care (1-5 unrelated children), or at large day care (> or = 6 unrelated children) was reported retrospectively by parental questionnaire when the children were approximately 6 years old. RESULTS: After adjusting for potential confounding variables, compared with children at home those in large day care had more frequent colds at year 2 (odds ratio [OR], 1.9, 95% confidence interval [CI], 1.0-3.4; P =.04), less frequent colds at years 6 (OR, 0.3, 95% CI, 0.1-0.9; P =.02) through 11 (OR, 0.4, 95% CI, 0.1-1.2; P =.09), and the same odds of frequent colds at year 13 (OR,1.0, 95% CI, 0.3-3.8; P =.95). In addition, compared with children in large day care for 1 year or less those attending large day care for more than 2 years had more frequent colds at year 2 (OR, 1.7, 95% CI, 1.0-3.0; P =.04), less frequent colds at years 6 (OR, 0.5, 95% CI, 0.2-1.1; P =.08), 8 (OR, 0.2, 95% CI, 0.1-1.0; P =.04), and 11 (OR, 0.3, 95% CI, 0.1-1.0; P =.05); and the same odds of frequent colds at year 13 (OR, 0.9, 95% CI, 0.3-2.9; P =.80). CONCLUSIONS: Attendance at large day care was associated with more common colds during the preschool years. However, it was found to protect against the common cold during the early school years, presumably through acquired immunity. This protection waned by 13 years of age.

Is there a common cold constitution?

OBJECTIVE: Constitutional factors might play a role in the susceptibility to clinical illness during the common cold. This study seeks to determine if the likelihood of developing frequent common colds persists during childhood. DESIGN: The Tucson Children's Respiratory Study involves 1246 children enrolled at birth and followed prospectively since 1980 and 1984. Parents reported the occurrence of frequent (> or =4) colds during the past year by questionnaire at 2, 3, 6, 8, 11, and 13 years of age. Blood for ex vivo interferon-gamma responses was obtained at 9 months and 11 years of age. RESULTS: After adjustment for potential confounding variables, children with frequent colds at year 2 or 3 were twice as likely to experience frequent colds at year 6 (relative risk [RR], 2.8; 95% confidence interval [CI], 2.1-3.9), year 8 (RR, 2.6; 95% CI, 2.1-3.3), year 11 (RR, 2.4; 95% CI, 1.8-3.1), and year 13 (RR, 2.1; 95% CI, 1.4-3.3) compared with children who had infrequent colds at years 2 and 3. At 9 months of age, children who ultimately experienced persistent frequent colds had lower interferon-gamma titers than children without persistent frequent colds (3.05 +/- 1.61 vs 3.74 +/- 1.39, P =.016); this finding persisted at 11 years of age. CONCLUSION: These data suggest the existence of a common cold constitution, whereby some children are more susceptible to infection and/or the expression of clinical symptoms when infected than are other children.

A pilot study of the use of guided imagery for the treatment of recurrent abdominal pain in children.

Few effective therapies are available for children with recurrent abdominal pain (RAP). Relaxation and guided imagery have been shown to impact the autonomic nervous system, which is altered in patients with functional gastrointestinal disorders. Ten children with RAP were enrolled in the study after evaluation by a pediatric gastroenterologist. They were trained in relaxation and guided imagery during 4 weekly 50-minute sessions. Pain diaries were completed at 0, 1, and 2 months. Children and parents also completed psychological questionnaires at enrollment. Although refractory to conventional treatment by their physician and pediatric gastroenterologist, the children experienced a 67% decrease in pain during the therapy (chi-square for trend, p < 0.001). No baseline psychological characteristics impacted the response to therapy. The use of relaxation along with guided imagery is an effective and safe treatment for childhood RAP.

Pediatricians' evaluations of their residency curriculum in emergency medicine.

OBJECTIVE: To describe residency graduates' perceptions of their preparation for providing pediatric emergency medical care. METHODS: The design was a cross-sectional survey set in a university-affiliated pediatric residency program. Twenty residency graduates from 1994 and 1995 who did not have an emergency department (ED) rotation (pre-ED group) and 24 graduates from 1998 and 1999 who had an ED rotation (post-ED group) participated in the study. The main outcome measures were residency graduates' responses regarding their preparation for various types of emergency situations and ratings of various residency curriculum components for usefulness in pediatric emergency medicine education. RESULTS: Nearly all residency graduates (98%) believed that they were well prepared to manage pediatric emergencies, and this did not differ between the pre- and post-ED groups (P = 1.0). For both groups, urgent care and critical care rotations were generally the highest ranked residency curriculum components for learning about four specific areas of pediatric emergency medicine (minor trauma, toxic ingestions, and medical and surgical emergencies). For the post-ED group, the ED rotation was also rated highly for each of these areas, but it was not the highest ranked for any of the four curriculum components. CONCLUSIONS: Despite limited access to rotations in a pediatric ED, our graduates were confident in their ability to manage pediatric emergencies. A pediatric emergency medicine curriculum composed of didactic teaching and clinical rotations in a pediatric intensive care unit and urgent care served as an effective way to supplement limited ED experience.

Cortisol circadian rhythms and stress responses in infants at risk of allergic disease.

Altered hypothalamic-pituitary-adrenal function associated with allergic disease has generally been thought to be secondary to the stress of chronic disease. However, recent studies suggest that altered cortisol circadian rhythm and cortisol stress hyper-responsiveness precede the inception of allergic disease and are possible links between preventive factors associated with the hygiene hypothesis and the development of allergies. Elevated endogenous cortisol responses to stressful stimuli could predispose susceptible hosts to atopy and allergic disease by biasing the developing immune system to a T helper 2-predominant immune response, greater total and allergen-specific serum immunoglobulin E responses, and/or inhibition of peripheral immune tolerance. Because glucocorticoid receptors are present throughout the human body and many genes contain glucocorticoid response elements, variances in endogenous cortisol concentrations could have an impact on the phenotypic plasticity of a wide range of immunologically active genes during early human immune development. Here, recent findings related to hypothalamic-pituitary-adrenal function in infants predisposed to developing allergic disease are discussed along with speculation regarding the potential causal role of endogenous cortisol in the inception of allergic disease.

Cortisol circadian rhythms and stress responses in infants at risk of allergic disease.

BACKGROUND: The cortisol circadian rhythm and response to stressful stimuli are altered in children and adults with allergic disease, including asthma. It is not known whether these alterations precede or follow the onset of allergic disease. OBJECTIVE: We sought to evaluate the cortisol circadian rhythm and stress response among infants at risk for the development of allergic disease. METHODS: Infants with and without risk factors for allergic disease were evaluated at age 6 months. Saliva was obtained at 8 am, 2 pm, and 8 pm at home (n = 68) by parents when their infants were comfortable and in the clinic (n = 88) before and after their physical examination and vaccinations. Information regarding parental allergy and exposure to other children at home or in child care were obtained by questionnaire. RESULTS: In multivariate analysis the circadian rhythm of cortisol was flattened because of the lack of the expected morning surge of cortisol, resulting in decreased diurnal variation of cortisol in infants of mothers with allergy (P = .035) or asthma (P = .002) or an asthmatic father (P = .022). The cortisol stress response was greater in infants of mothers with allergy (P = .045) or asthma (P = .039), those with fewer siblings (P = .066), and those not entering day care early in life (P = .017). CONCLUSIONS: These alterations in both basal and stress levels of endogenous cortisol among infants predisposed to allergic disease might affect the development of allergic immune responses early in life through interactions with inflammatory mediators.

Systematic review of treatments for recurrent abdominal pain.

OBJECTIVE: To conduct a systematic review of evaluated treatments for recurrent abdominal pain (RAP) in children. METHODS: Online bibliographic databases were searched for the terms "recurrent abdominal pain," "functional abdominal pain," "children," or "alternative therapies" in articles classified as randomized controlled trials. The abstracts or full text of 57 relevant articles were examined; 10 of these met inclusion criteria. Inclusion criteria required that the study involve children aged 5 to 18 years, subjects have a diagnosis of RAP, and that subjects were allocated randomly to treatment or control groups. The methodology and findings of these articles were evaluated critically, and data were extracted from each article regarding study methods, specific interventions, outcomes measured, and results. RESULTS: Studies that evaluated famotidine, pizotifen, cognitive-behavioral therapy, biofeedback, and peppermint oil enteric-coated capsules showed a decrease in measured pain outcomes for those who received the interventions when compared with others in control groups. The studies that evaluated dietary interventions had conflicting results, in the case of fiber, or showed no efficacy, in the case of lactose avoidance. CONCLUSIONS: Evidence for efficacy of treatment of RAP in children was found for therapies that used famotidine, pizotifen, cognitive-behavioral therapy, biofeedback, and peppermint oil enteric-coated capsules. The effects of dietary fiber were less conclusive, and the use of a lactose-free diet showed no improvement. There seemed to be greater improvement when therapy (famotidine, pizotifen, peppermint oil) was targeted to the specific functional gastrointestinal disorder (dyspepsia, abdominal migraine, irritable bowel syndrome). The behavioral interventions seemed to have a general positive effect on children with nonspecific RAP. Many of these therapies have not been used widely as standard treatment for children with RAP. Although the mechanism of action for each effective therapy is not fully understood, each is believed to be safe for use in RAP.