Gösta Alfvén

School stressors, psychological complaints and psychosomatic pain

Background: The proportion of Scandinavian school children reporting psychosomatic pain and psychological complaints have increased in recent decades. In this study we investigated these symptoms in relation to potential stressors in the school environment.

Stressor, perceived stress and recurrent pain in Swedish schoolchildren

OBJECTIVEnStress is an important etiological factor for pain. Little is known, however, about how this process is mediated. The aim of this study is to highlight how more stress corresponds with the amount of reported perceived stress, pain symptom, and the co-occurrence of two pain symptoms--headache and abdominal pain--and how these three phenomena are related. We have also studied possible gender differences.nnnMETHODSnA cross-sectional study based on data from child supplements linked to national household surveys in Sweden during 2002-2003. Information concerning harassment, perceived stress, headache, and abdominal pain was gathered from a questionnaire. The study population consisted of a representative national sample of 2597 children aged 10-18 years.nnnRESULTSnChildrens reports of exposure to the stressor harassment were associated with their subjective perception of stress and recurrent pain in a stepwise manner. Having both pain symptoms was more strongly associated with the stressor harassment and perceived stress than having only one pain symptom. This was especially true of girls, who reported higher levels of stress symptoms and who had a different profile of pain symptoms than boys.nnnCONCLUSIONSnThe stressor harassment, perceived stress, and recurrent pain are associated with each other in a stepwise fashion. The co-occurrence of headache and abdominal pain is much more closely associated with harassment and perceived stress than any of these symptoms separately, especially in girls.

Long-chain polyunsaturated fatty acids in human milk and brain growth during early infancy.

Long‐chain polyunsaturated fatty acids are essential for growth and development, and their crucial role in the development of the central nervous system and in retinal function has been the subject of many studies. As the balance between n‐6 and n‐3 fatty acids has to be optimal, their concentrations in the milk given to infants who are exclusively breastfed is of major importance. In this study, the composition of fatty acids in mothers milk and the growth rate of the infant brain were analysed. Nineteen mother‐term infant pairs from Stockholm, Sweden, were studied from birth to 1 mo and 3 mo of age, during which time the infants were breastfed exclusively. The dietary intake of the mothers was calculated and found to concur with the recommended daily dietary allowances of Swedish lactating women as regards energy, protein, fat and carbohydrates. The amounts of linoleic acid and α‐linolenic acid in the diet were similar to those reported for European and North American women. The ratio between arachidonic acid (AA) and docosahex‐aenoic acid (DHA) in the milk from Swedish mothers is approximately the same as in the brain of infants, and was found to be positively correlated with the rate of gain of the occipito‐frontal head circumference and of the calculated brain weight at 1 mo (p < 0.01) and 3 mo (p < 0.01) of age, respectively. However, further studies are needed to establish the exact requirements of AA and DHA for optimal growth and development during early infancy in exclusively breastfed infants.

SMS pain diary: a method for real-time data capture of recurrent pain in childhood

Objectives:u2002 To capture recurrent pain in children aged 9–15u2003years reported by short message service (SMS) and to test the compliance of such reporting in a pilot study.

Elevated cholecystokinin concentrations in plasma in children with recurrent abdominal pain.

The objective of the present study was to measure plasma Concentrations of the gastrointestinal hormones gastrin, somatostatin and cholecystokinin in plasma of children with recurrent abdominal pain. since these hormones affect gastrointestinal function. Forty‐four children (7–16 years old) with recurrent abdominal pain and 36 control children (matched for age and sex) participated in the study. In a blood sample collected after an overnight fast, gastrin, somatostatin and cholecystokinin concentrations werc measured by radioimmunoassay. The children with recurrent abdominal pain had higher plasma cholecystokinin levels (p<0.001) than the controls. Whether or not this aberration is related to the clinical symptoms of children with recurrent abdominal pain remains to be established.

LONGTERM FOLLOW-UP OF NEONATAL SEPTICEMIA

ABSTRACT. The longterm prognosis of neonatal septicemia during the first four weeks of life has been estimated. Of 90 infants with the diagnosis of neonatal septicemia during a five‐year period, 1969–1973, 65 infants survived the initial treatment. Another two infants died with complications of their main disease, intestinal atresia, at the age of two months. Thus the total mortality in neonatal septicemia in this series was 30%. The remaining 63 children have been investigated between ages of 21/2 and 61/2 years. Of these 63 children we have found 14 children (22% of the surviving) with handicaps where the septicemia can be regarded as a possible cause of the handicap. Of these 14 children only six had an “uncomplicated” septicemia while four of them had meningitis and four had osteomyelitis. Furthermore, of the 14 handicapped children nine were delivered preterm (28–36 weeks) and all of them had one or more additional neonatal diagnoses than septicemia. The prognosis, both immediate and longterm, of neonatal septicemia in the present series compares favourably to most international studies. The importance of early detection together with an aggressive treatment of the septicemia is stressed and is considered as the main reason for the good prognosis.

Validity and reliability of a new short verbal rating scale for stress for use in clinical practice.

Stress is a common experience that affects the body and the brain in many ways. It can sometimes be of interest in research and clinical practice to measure the intensity of single stress reactions. For example, data on intensity can be important for understanding factors such as stress-related behaviour and pain and for a better understanding of physiological stress reactions in hormones, muscles and the circulatory system. Stress can be measured in a number of ways, including shifts in the production of cortisol and adrenaline and in skin conductance. But performing such tests is not without its difficulties, and the results can be hard to evaluate. An alternative to physiological measurements is verbal instruments. According to a search at PubMed in November 2013 and discussions with colleagues, those that have been developed so far involve many issues and, as a result, take time to answer. Two examples are the State-Trait Anxiety Inventory for Children (STAIC) with 20 items (1) and the Multidimensional Anxiety Scale for Children (MASC) with 37 items (2). However, there is a need for an instrument that assesses the intensity of single stress attacks in a simple, valid and reliable way, and we have not been able to find one. A short verbal rating scale for stress (VRSS), reporting recent or present experience of stress and easy to use in clinical routine settings and research, would meet this demand. An important issue in the development of such an instrument is how it operates, including the theoretical framework, the context of the application and the selection of optimal responses. These are also the key factors that define how we measure the quality of an instrument (3). Instruments capturing stress should be valid and reliable, easy to understand and use and have good compliance. The aim of this study was therefore to test a new VRSS developed by one of the authors. The material consisted of two samples. The first included 28 children, seven boys and 21 girls, with a mean age of 12.6 years (range: seven to 16) visiting a clinic for recurrent pain. The second sample consisted of 34 children, 15 boys and 19 girls, aged 11.3 years (range: eight to 16). Fifteen of them were recruited from the same clinic as the first sample, and 19 were recruited from a clinic for children with needle phobias. All the children indicated that they knew what stress was and all of them were able to describe their own feeling of stress. After a brief talk about the child’s stress reaction, the child was asked to describe their latest stressful experience in a few words. For the children attending the pain clinic, this incident had happened during the last few days and not longer than a week ago. The children with needle phobias described the stress they felt when they came in for a practice injection. The researchers used a new verbal rating scale for stress (VRSS), based on a scale of zero to five, that had been developed, tested and retested in school age children, in collaboration with two psychologists. The VRSS provides an easy to understand scale that offers the children alternative responses when it comes to describing an increase in their stress levels (see Appendix). Validity of a scale is best evaluated by comparing it with a validated scale measuring the same parameter. But such a scale could not be found, so we measured the agreement between the VRSS and a visual analogue scale (VAS) measuring the same phenomenon. This was done in both groups. The child was asked to choose one of six alternatives on the VRSS to report how strong the latest experienced stress (VRSS1) was and to report the same experience on a visual analogue scale (VAS1) with the written anchors ‘no stress’ and ‘the worst known stress.’

Children with recurrent psychosomatic abdominal pain display increased morning salivary cortisol and high serum cortisol concentrations.

Cortisol is an important regulator of the intermediate metabolism during both homeostasis and stress (1,2). Measurements of cortisol concentration in saliva are independent of the secretion rate, indicate the amount of free biologically active cortisol and increase quite rapidly, only a few minutes after the increase in the blood (3,4). Previous studies in children with recurrent abdominal pain (RAP) of psychosomatic origin have reported higher total cortisol secretion and higher morning salivary cortisol concentrations in both genders, compared to age and gender-matched healthy children, but normal concentrations at noon and in the evening (5). In a paper in the same field, Alfv en et al. found that morning serum cortisol levels were lower in children with RAP of non-organic origin (6). To explore if this discrepancy between saliva and serum levels was something to be expected in this group of children or not, we carried out a study of psychosomatic abdominal pain, analysing both salivary and serum cortisol in the same child and how they correlated (group A). To the best of our knowledge, this has not been studied previously. We also wanted to study if we could repeat the increased morning salivary concentrations seen in our first salivary cortisol study (group B), and, if so, whether the results became stronger when we put the two groups together. Group A comprised 24 children – five boys and 19 girls – with a mean age 11 years and a range of seven to 16 years, with a diagnosis of RAP who fulfilled the criteria of von Bayer and Walker (7). They were all consulting the same doctor at an outpatient clinic in Greater Stockholm that specialised in recurrent childhood pain and were included consecutively. Of these, 20 fulfilled the diagnostic criteria for psychosomatic recurrent pain (8). Four children had stressrelated pain, but due to the short follow-up time they only fulfilled five of the seven criteria for psychosomatic diagnosis. An organic cause was excluded in all patients. The criteria for psychosomatic diagnosis are excluding an organic cause and fulfilling six of the following seven criteria: (i) onset or aggravation of chronic negative stress at the time of onset of recurrent pain, (ii) pain in parallel with chronic negative stress, (iii) feeling better or pain-free during periods of no or lessened chronic negative stress, (iv) acute stress induced pain, (v) most pain attacks related to acute stress, (vi) the child is followed up for at least one year, (vii) the parent or child and their doctor agree on the diagnosis. The children all had a history of RAP for an average of 18 months (range 3–60) and 12 of them also had recurrent headache. All children and parents agreed with the seventh criteria. The inclusion criteria for group B (8) was the same as for group A. Group B consisted of 35 children – 26 girls and 9 boys from the same catchment area in Greater Stockholm, with a mean age of 12.3 years and a range 6.7–18 years. When group A and B were combined they consisted of 52 children – 14 boys and 38 girls with a mean age of 10.9 years and a range 6.7–18 years. There were 20 children (38%) in the combined group who were not Swedish or whose parents had not been born in Sweden. Their socioeconomic status was low to middle class. No other severe health conditions were present and none of the children received continuous pharmacological therapy. Group C was the control or reference group, which comprised 296 healthy children – 153 girls and 143 boys – aged from 6 to 15 years of age. The control group included children from one school from a middle-sized town, with more children from an agricultural area and fewer immigrants (about 20%) than Groups A and B. Their socioeconomic status was middle class. This difference in

Antinociceptive fatty acid patterns differ in children with psychosomatic recurrent abdominal pain and healthy controls

Stress is considered to trigger psychosomatic recurrent abdominal pain (RAP), but the mechanism behind the pain is unclear. Because the essential fatty acids, omega‐6 and omega‐3, are involved in pain, by regulating lipid mediators, we analysed the fatty acid patterns in children with RAP compared to healthy children.