Chronic Abdominal Pain in Childhood: Diagnosis

and Management
ALAN M. LAKE, M.D.
Johns Hopkins University School of Medicine
Baltimore, Maryland
More than one third of children complain of abdominal pain lasting two weeks or longer. The
diagnostic approach to abdominal pain in children relies heavily on the history provided by the
parent and child to direct a step-wise approach to investigation. If the history and physical
examination suggest functional abdominal pain, constipation or peptic disease, the response
to an empiric course of medical management is of greater value than multiple "exclusionary"
investigations. A symptom diary allows the child to play an active role in the diagnostic
process. The medical management of constipation, peptic disease and inflammatory bowel
disease involves nutritional strategies, pharmacologic intervention and behavior and
psychologic support.

Chronic abdominal pain in children is defined as pain of more than two weeks' duration. 1

The pain may be persistent or recurrent. It is a frustrating concern to the child, the parents and
the physician. The differential diagnosis of abdominal pain in children varies with age,
gender, genetic predisposition, nutritional exposure and many environmental factors. While
efforts to distinguish organic from functional abdominal pain are admirable, these apparently
opposing etiologies are not mutually exclusive in children, since psychologic complications
of organic disease are common.

The diagnosis of abdominal pain in children has five components. The relative value of each
component depends on the child's age and, in some cases, on the level of cooperation of the
child and parents. The five components include the history, a physical examination,
laboratory testing, results of imaging studies and response to empiric therapy. This approach
is summarized in Table 1.

TABLE 1
Five Components of the Evaluation of Children with
Abdominal Pain
History
• Location, intensity, character and duration of pain, time of day or night that
pain occurs
• Appetite, diet, satiety, nausea, reflux, emesis
• Stool pattern, consistency, completeness of evacuation
• Review of systems: weight loss, growth or pubertal delay, fever, rash
• Medications and nutritional interventions
• Family history, travel
• Interference with school, play, peer relations and family dynamics
Physical examination
 • Weight, height, growth velocity, pubertal stage, blood pressure
• Complete physical examination
• Objective abdominal findings: location, rebound, mass, psoas sign
• Liver, spleen and renal size, ascites, flank pain
• Perianal findings: rectal and pelvic examinations, stool testing for occult blood
Laboratory tests
• Complete blood count with differential, erythrocyte sedimentation rate
• Urinalysis and urine culture
• Laboratory tests individualized according to indication
--Stool testing and culture for polymorphonuclear leukocytes, parasites,
Giardia antigen
--Serum chemistry profile, amylase level
--Pregnancy test, cultures for sexually transmitted diseases
--Breath hydrogen test: lactose, fructose
--Serologic testing for amebae, Helicobacter pylori
Imaging studies individualized according to indication
• Abdominal and pelvic sonography
• Upper gastrointestinal contrast study with small bowel testing, abdominal
computed tomography
• Upper endoscopy, colonoscopy, laparoscopy
Empiric interventions
• Patient and parent education
• Symptom diary of pain, bowel pattern, diet and associated features, response
to intervention
• Constipation investigated as a factor
• Dietary interventions, including adjusted fiber intake, reduced lactose intake,
reduced juice intake
• Trial of peptic management

Diagnostic Evaluation
History
The location of the pain is defined by the specificity. The child may indicate the location of
the pain by pointing with one finger or with the whole hand. Apley's observation that "the
1

further the pain from the umbilicus, the greater the likelihood of organic disease" has held up
well. Children may rate the intensity of the pain on a scale of 1 to 5 or 1 to 10 or, for younger
children, by pointing to a series of faces graded from smile to frown to tears. Since children
may not understand such definitions of character as "burning," "sharp" or "dull," it is best to
phrase questions about the nature of the pain at their level of understanding. Some examples
of questions might be, "Does it hurt like a needle? Does it feel like butterflies in your
stomach? Does it help to eat? Does it help to lie down or to poop?"

Night pain or pain on awakening suggests a peptic origin, while pain that occurs in the
evening or during dinner is a feature of constipation. Children often deny heartburn, but other
features of peptic disease include early satiety, nausea and the complications of
gastroesophageal reflux. A diary that lists diet, symptoms and associated features for three to
seven days is invaluable since it will indicate potential causes of the symptoms, such as
exposure to lactose or the failure to have a normal bowel movement. The diary also should
include any interventions initiated by the child or the parents.

The review of systems will focus on features that may be related to abdominal pain, such as
documented weight loss or gain, height growth, fever, joint complaints and rash. The presence
of one or more of these signs suggests an inflammatory Since excessive undigested
carbohydrates may contribute to
or infectious disease process. The respiratory
abdominal pain, an empiric trial of
complications of gastroesophageal reflux, including lactose elimination or reduction of
excessive juice intake is often
chronic cough, reactive airway disease or persistent appropriate.
laryngitis, may be more prominent than emesis or chest
pain. A careful review of recent medications will indicate whether the pain may respond to
empiric therapy; for example, antibiotics may predispose the patient to intestinal bacterial
overgrowth, acne medications may induce esophagitis and tricyclic antidepressants may cause
constipation.

The family history of peptic disease, irritable or inflammatory bowel disease, pancreatitis,
biliary disease or migraine is determined. The influence of pain on the child's daily activity is
assessed through questions about school attendance, athletic endeavors and peer relationships.
Whenever possible, a few minutes should be taken alone with adolescents to address concerns
in the absence of parents and to elicit honest answers about sexual issues, psychologic fears
and the disruptions to lifestyle caused by the parents' interventions.

Physical Examination
Because of the interaction betweeen abdominal pain, nutrition and demands of growth, the
anthropometric data of weight, height and growth velocity are documented. Blood pressure is
recorded and the weight-for-height is plotted to assess malnutrition or obesity. The
examination is generally completed before focus on the abdomen is initiated. If distention is
reported, the abdominal girth at the umbilicus should be documented. The physician should
percuss the liver span, document the spleen and kidney size and determine the influence of
leg motion (psoas sign). Examination for pain should be performed with gentle and deep
pressure as well as with rebound. Abdominal and rectal examinations will identify
constipation, the inflammatory mass of Crohn's disease, abdominal tumors such as
neuroblastoma or Wilms' tumor and the presence of umbilical or abdominal wall hernias. The
stool should be tested for blood. The pelvic examination may suggest gynecologic problems,
such as endometriosis, ectopic pregnancy or ovarian cysts or torsion.

Laboratory Testing
The routine screening laboratory evaluation of abdominal pain in children includes the
complete blood cell count with differential and erythrocyte sedimention rate to evaluate for
anemia, leukocytosis and chronicity. Platelet counts are frequently elevated in inflammatory
diseases. Urinalysis and routine urine culture are indicated. A sample to check the stool for
blood is obtained during the rectal examination and the result is often confirmed with three
additional outpatient sample cards used at home.

Additional laboratory investigations are chosen on the basis of the history and physical
examination. These investigations include stool culture, stool testing for parasites or Giardia
2

antigen, a chemistry profile to evaluate liver enzymes and amylase, and serology testing for
Helicobacter pylori or amebae. Carbohydrate breath testing for lactose intolerance is
indicated if empiric dietary interventions are inconclusive.

Imaging Investigations
Sonography of the abdomen and pelvis is usually performed first to exclude nonintestinal
origins of the pain. The limitations of isolated biliary or renal sonography should be avoided.
Pelvic sonography is indicated because of its sensitivity for free fluid, the frequency of
retroperitoneal disease and the visualization of the ileum for Crohn's disease, adenopathy and
chronic features of abscess from fistulas or Meckel's diverticulum.

If sonography reveals no abnormalities and either chronic peptic disease or irritable bowel
disease is suspected, an upper gastrointestinal series A high fiber intake may aggravate
with small bowel testing is indicated. If the upper constipation initially by increasing
bulk in the absence of contractile
gastrointestinal tract is the only site of investigation, far tone.
too much disease may be missed. Barium enema is
indicated primarily in the context of obstruction or chronic intussusception. Abdominal
computed tomographic (CT) scan with contrast allows evaluation for extra-intestinal mass
lesions, abscess and retroperitoneal disease.

Upper endoscopy is rarely indicated as a first-line investigation. Biopsies of the esophagus,

3

gastric antrum and duodenum may be indicated even in the absence of macroscopic disease to
identify microscopic diagnostic features of eosinophilic gastritis, reflux esophagitis, H.
pylori, granuloma of Crohn's disease and villus injury with enteropathy. Colonoscopy has
replaced barium enema in the evaluation of pain with chronic diarrhea or bleeding. 4

Empiric Intervention
The child's response to empiric intervention is part of the diagnostic evaluation. Before
visiting a physician for a chronic complaint, most parents will have initiated a trial of dietary
interventions, over-the-counter medications for acid suppression or laxatives. Unfortunately,
such attempts at management may also include withdrawing the child from activities
perceived to be too stressful, such as advanced academic programs or sports, and this may be
more significant in terms of the child's self-confidence and sense of wellness than in terms of
contribution to the pain.

The first step in empiric treatment is educating the child and parents about the differential
diagnosis and options for appropriate intervention. A prospective symptom diary should be
used to document the frequency of the pain, related events and response to intervention. Since
children often have erratic stool frequency, an appropriate empiric intervention is the addition
of a fiber supplement to rule out constipation as a variable. Fiber tablets may be used in
children older than 10 years and, in younger children, the newer, more palatable fiber
powders may be mixed in juice or mixed and frozen in juice to make homemade popsicles.

Since excessive undigested carbohydrates may contribute to abdominal pain, an empiric trial
of lactose elimination or reduction of excessive juice intake is often appropriate. Empiric
5

trials of antispasmotic, anxiolytic or antidepressant medications are not indicated. Trials of

antacids are rarely of value since symptomatic relief is limited to children with esophagitis,
and compliance with a full course of therapy is rarely achieved. If the history and physical
examination suggest the pain has a peptic origin, a trial of therapy with histamine H blockers
2

may be indicated before confirmatory investigations are started (Figure 1).

Evaluating for Peptic Disease

FIGURE 1. An algorithmic approach to the child with probable peptic

disease.
Specific Disease States
Recurrent Abdominal Pain Syndrome
Recurrent abdominal pain syndrome is a prepubertal functional pain with two distinct peaks
of frequency. The first peak occurs between five and seven years of age, with equal frequency
in boys and girls and in 5 to 8 percent of children. It is often attributed to the adjustment to
parental separation when starting school. The second peak, with a prevalence approaching 25
percent, occurs between eight and 12 years of age and is far more prevalent in girls. The pain
6

is vague (identified by the patient's whole hand at the umbilicus) and is unrelated to meals,
activity or stool pattern. Patients are not awakened by the pain. An epigastric location is
reported by 10 percent of patients. It is accompanied by autonomic features such as pallor,
nausea, dizziness, headache and fatigue. The family history is often positive for functional
bowel disease such as irritable bowel syndrome. The physical examination is striking for its
7

normality, and the screening laboratory investigations are by definition normal.

The management of recurrent abdominal pain begins with the acknowledgement that the pain
is real, that extensive investigations are not warranted and that the child must emphasize
normality by remaining in school, continuing activities and resuming a normal diet.
Psychologic evaluation and management will be necessary if the degree of incapacity persists.
In older children and adolescents, a component of recurrent abdominal pain syndrome is seen
in cases of depression or panic disorder with a learned symptomatic conversion reaction and
associated weight loss. The performance of laboratory tests with negative results may increase
the level of anxiety in older children.

True irritable bowel syndrome occurs infrequently before late adolescence. It is best
7

characterized as an intestinal dysmotility with intervals of nuisance diarrhea or constipation.

The pain is dull, crampy and located in the left lower quadrant or periumbilical region. As in
cases of recurrent abdominal pain syndrome, autonomic features are common. Stress is
implicated in the flare-up of symptoms, and a positive family history is common.
Management includes dietary factors such as exclusion of contributory lactose intolerance and
the addition of fiber to the diet, instruction in stress management techniques and, rarely, the
use of antispasmotic medications.

Constipation
Constipation is a major cause of chronic abdominal pain in children from toddler age to the
preteen years. Constipation is best defined as the failure to achieve complete evacuation of the
lower colon rather than in terms of infrequency or firmness of stool. The etiology of
constipation in most children is an interval of being "too busy" to evacuate completely,
producing a dilated lower colon, erratic stool patterns and frequent encopresis. The parents
usually do not understand what is causing the child's discomfort. The child avoids passing the
hard stool. The diet is usually high in constipating foods (i.e., cheese, pasta, starches) and low
in fiber. The process is usually quite advanced before the family physician is made aware of
the problem. Aside from complicating encopresis and bleeding from rectal fissures, symptoms
include crampy pain that occurs during large meals and varies greatly in intensity, reduction
in appetite and distention of the abdomen (from stool and gas) that occurs in the evening.

The management goal is complete evacuation of the lower colon on a nearly daily basis. This
is achieved by whatever means is necessary until muscle tone can be restored over two to six
months. Initially, a high fiber intake may aggravate the process as a result of increasing bulk
8

in the absence of contractile tone. Therefore, stool softeners such as lactulose (Duphalac) or
mineral oil are used first. These are combined with "motivation to go," which can be achieved
in some children with behavior-modification sticker charts but usually requires a stimulant
medication such as magnesium hydroxide (Milk of Magnesia) or senna (Senokot). The child
is encouraged to establish the "habit" of toilet use with the use of a daily calendar, rewards for
attempting defecation and rewards for absence of encopresis. Dietary efforts begin with
reducing intake of constipating foods and eventually including increased fiber. Initial
management may require use of an enema or suppository, which is repeated only if failure to
evacuate exceeds three days. Both softening and stimulant medications are initiated at
dosages of one to three teaspoons daily and adjusted to the response of averaging two soft
stools a day for six to eight weeks. At that point, most children can tolerate a transition to
increased dietary fiber and habitual toilet use.

Peptic Disorders
The peptic disorders include reflux esophagitis, antral gastritis, gastric and duodenal ulcer,
and H. pylori infection. Gastroesophageal reflux in children has recently been reviewed in
another article. 9

As we mentioned in the section on history, the signs and symptoms of peptic disease include
early morning pain, early satiety, night arousal and a positive family history. The pain may be
epigastric or periumbilical and is remarkably consistent in character. Occult bleeding is
frequent with ulceration and less common in gastritis. 10

The major risk factor for peptic ulcer disease in childhood is genetic predisposition: 50
percent of children with duodenal ulcer have a first-degree relative with peptic ulcer disease.
The prevalence of duodenal ulcer is two to three times higher in boys than in girls. Gastric
ulcer occurs substantially less often than duodenal ulcer, but the prevalence is equal in boys
and girls. The approach to peptic management is summarized in Figure 1.

Stress ulcers account for more than 75 percent of peptic disease in infants and young children.
Stress ulcers usually present with acute, relatively painless, dramatic upper gastrointestinal
bleeding, features shared with gastric ulceration resulting from use of nonsteroidal anti-
inflammatory drugs (NSAIDs). Zollinger-Ellison syndrome with a gastrin-producing tumor
10

is very rare in children; the diagnosis is pursued only in children with multiple ulcers. Acute
bleeding is common in children with chronic renal failure, sickle cell disease, cystic fibrosis
and cirrhosis.

Antral gastritis is a common peptic presentation in children. Children present with chronic
epigastric pain, early satiety with nausea, modest weight loss and a low frequency of family
history of peptic disease. Gastric emptying is impaired, and reflux symptoms may be
prominent. Results of the stool test for occult blood are usually negative. Radiographic studies
are either normal or demonstrate pylorospasm. Many children with antral gastritis have an
acute onset of gastritis, often in the context of a viral-like illness.

Endoscopic investigation is generally indicated in the context of active, persistent or recurrent

bleeding, with significant morbidity from weight loss, anorexia or chest pain, or for
clarification of abnormal findings on radiographic studies. Children with suspected but
uncomplicated peptic disease are usually treated with H blockers, with endoscopy deferred
2

for pain that persists for more than four weeks, recurrent disease, suspected H. pylori or
exclusion of eosinophilic gastritis or enteropathy. 4

The medical management of peptic disease is summarized in Table 2. Sucralfate (Carafate),

an aluminum sucrose gel, is particularly effective in the treatment of medication-induced
gastritis.

TABLE 2
Management of Childhood Peptic Disease
Drug Availability Dosage
H -receptor blockers
2

Cimetidine 300 mg per 5 mL, 200-, 20 to 40 mg per kg per day, in

(Tagamet) 300-, 400-, 800-mg tablets divided doses every 6 hours
Ranitidine (Zantac) 75 mg per 5 mL, 150-, 300- 4 to 8 mg per kg per day, in divided
mg tablets doses every 8 to 12 hours
Nizatidine (Axid) 150-, 300-mg capsules* 4 to 8 mg per kg per day, in divided
doses, every 12 hours
Famotidine 40 mg per 5 mL, 20-, 40- 1 to 2 mg per kg per day, once or
(Pepcid) mg tablets twice daily, maximum dosage: 40
mg per day
Proton pump inhibitors
Omeprazole 10-, 20-mg capsules* 0.5 to 3 mg per kg per day, in
(Prilosec) divided doses every 12 hours
Lansoprazole 15-, 30-mg capsules* 0.3 to 1.5 mg per kg per day, in
(Prevacid) divided doses every 12 hours
*--Since no liquid formulations are available at this time, the capsules are opened,
and the contents are mixed in an acidic vehicle such as apple juice, applesauce or
yogurt.
NOTE: Medication is taken on the schedules given for six to eight weeks, then once
daily for four weeks. Diet--Patients should be instructed to eat multiple modest
meals and avoid overeating, to minimize caffeine intake and to avoid eating foods
that appear to cause pain. Heartburn--To reduce heartburn, patients can be
instructed to take an antacid such as Mylanta, Maalox or Milk of Magnesia, in a
 dosage of 0.5 mL per kg per dose 1 hour after meals and at bedtime, or a low-dose,
over-the-counter histamine H -blocker such as Tagamet, Pepcid, Zantac or Axid, at
2

one half the usual prescription dosage. Mucosal protection--To enhance mucosal
protection, patients can take sucralfate (Carafate) and/or bismuth subsalicylate
(Pepto-Bismol) or ranitidine bismuth citrate (Tritec).

The dosages of H blockers may seem high, especially since medication is usually given three
2

times daily during the first two weeks of therapy, but acid secretion in children reaches adult
levels by the age of four months. Regrettably, none of the medications employed for peptic
10

disease have been approved by the U.S. Food and Drug Administration for use in children,
and family physicians who are not familiar with pediatric peptic management are encouraged
to coordinate care with a pediatric gastroenterologist.
Since acid secretion reaches adult
Proton pump inhibitors are generally employed only levels by the age of four months,
after endoscopic biopsy confirmation of failure to high doses of H receptor
2

antagonists may be used when

respond to H blocker therapy. Until additional
2
needed in children with peptic
information is available about the safety of long-term disease.

use, proton pump inhibitors are usually prescribed for

intervals of two to four months. 11

In 1984, Marshall and Warren demonstrated the role of a gram-negative aerophilic

12

bacterium, H. pylori, in chronic gastritis and peptic ulcer disease in adults. Drumm and
colleagues quickly confirmed the role of Helicobacter in chronic antral gastritis in children.
13

This bacterium produces a cytotoxin, urease, mucinase and superoxide dysmutase, which act
in concert to produce gastric and/or duodenal injury. Exposure to the bacterium, as measured
by antibody production, increases throughout childhood in the United States, reaching 11
percent by five years of age, 20 percent by 10 years of age and 45 percent by the late teens. 14

Since this rate of seroconversion is far in excess of the rate of documented peptic disease, the
significance of an isolated positive serologic test result is unknown.

The best described clinical syndrome in childhood is antral gastritis, which features early
satiety, epigastric abdominal pain and nodular antral gastritis on endoscopy. Studies
addressing the role of Helicobacter in less peptic conditions such as recurrent abdominal pain
syndrome have been inconclusive to date. Recognizing the limitations of a positive serology
15

result and the research status of the C-13urease breath test, the diagnosis in children has been
dependent on documentation of the bacterium in endoscopic biopsies of the stomach and
duodenum. Most children receive quadruple therapy with continued acid suppression
combined with a two- to three-week course of amoxicillin or clarithromycin (Biaxin),
metronidazole (Flagyl) and bismuth subsalicylate (Pepto-Bismol). This treatment regimen is
16

successful in approximately 90 percent of patients. Endoscopic confirmation of healing is

indicated with recurrent or persistent symptoms. Antibiotic resistance is an increasing
concern, so empiric treatment for possible Helicobacter infection is discouraged.
Periodic Syndrome or Cyclic Vomiting/Abdominal Migraine
Gee's original description of a syndrome with "fits of vomiting ... with disease-free intervals"
in 1882 has held up well in the clinical definition of periodic syndrome, which is now called
cyclic vomiting syndrome or abdominal migraine of childhood. Children present with
17

episodic nausea, abdominal pain and usually significant emesis, typically beginning during
the night or early morning hours and lasting from six to 48 hours, with intervening intervals
of weeks to months with no symptoms or findings at all. The majority of children have a
family history of migraine and may have other autonomic features such as pallor, explosive
diarrhea, lethargy and tachycardia. Of note, headache is rare in children with cyclic vomiting
syndrome, although it may evolve into more classic migraine in adolescence. Treatment is
usually early intervention with antiemetics or migraine medications.

Inflammatory Bowel Disease

Abdominal pain is frequently reported in children with ulcerative colitis and Crohn's disease.
The pain, which typically occurs in the lower abdomen, is cramping in nature and increases
after meals or activity. The pain is reduced by eating smaller meals, which contributes to the
anorexia and growth impairment that occur in children with inflammatory bowel disease. The
diagnosis is relatively easy when the child has bloody diarrhea, the need to defecate during
the night, perianal disease or an ileal mass on abdominal examination. More subtle features
include delayed puberty, anemia that is unresponsive to iron therapy, recurring oral aphthous
ulcers, chronic liver disease, or large joint synovitis or arthritis. The diagnosis is established
18

by small bowel barium contrast x-ray and colonoscopy with biopsies. The management of
inflammatory bowel disease in childhood is summarized in Table 3. 19

TABLE 3
Management of Inflammatory Bowel Disease in Children
Supportive care for child and family
• Provide educational materials for child, parents, teachers
• Give information about support groups for children and parents
• Offer psychologic counseling for depression, denial and noncompliance
• Expect reactive self-manipulation of medication dosages and diet

Nutritional support
• Correct deficits of macronutrients and micronutrients
• Deliver 125 percent of calories for height age
• Recommend routine multivitamin and mineral supplements
• Discourage "quick cure" diets and fads
• Administer intravenous nutrition to patients with intractable Crohn's disease or
fistula and before surgery
• Consider consumption of an elemental diet as primary therapy in patients with
small bowel Crohn's disease

Anti-inflammatory/immunomodulatory medication
• Prednisone (oral, intravenous, topical enema)
--Valuable in all forms, but use must be balanced against side effects
--Useful as chronic alternate-day therapy in adolescent patients with Crohn's
disease
 • Salicylates: sulfasalazine (Azulfidine), mesalamine (Asacol, Pentasa, Rowasa),
aminosalycylic acid (Paser Granules)
--Valuable in treating mild to moderate colitis
• Metronidazole (Flagyl; possibly ciprofloxacin [Cipro] as well in older children)
--Useful in treating Crohn's perianal or fistula disease
--Also useful in treatment of complicating Clostridium dificile infection
• Azathioprine (Imuran)/6-mercaptopurine (Purinethol)
--Valuable in treating moderate to severe Crohn's colitis, ulcerative colitis
• Fish oil (EPA, Sea Omega, Promega)
--Valuable in treating mild ulcerative colitis

Surgical resection
• Total colectomy is curative in cases of ulcerative colitis
• Useful in cases of toxic megacolon, and dysplasia in patients with ulcerative colitis
• Useful in treating Crohn's obstruction, fistula, abscess
• Useful when medical therapy fails or side effects of medication are intolerable
Information from O'Gorman M, Lake AM. Chronic inflammatory bowel disease in
childhood. Pediatr Rev 1993;14:475-80.

Final Comment
Once the etiology of chronic abdominal pain is established, the process of patient and family
education has just begun. Careful follow-up is necessary to monitor compliance with
treatment, restoration of normal activities and appropriate family interventions. Children do
not like to feel "different," and they often resist the need for long-term nutritional or
pharmacologic intervention. Growth parameters must be followed carefully. Support groups
for the family and the child can be invaluable. Most importantly, the child must feel that the
family physician understands that the pain is real, that the child's input is as valuable as the
parents' and that information shared in confidence will be kept confidential if at all possible.

The Author
ALAN M. LAKE, M.D.,
is associate professor of pediatrics at Johns Hopkins University School of Medicine,
Baltimore, and a practicing pediatrician and pediatric gastroenterologist with Flagship Health,
Lutherville, Md. Dr. Lake is a graduate of the University of Cincinnati College of Medicine
and served a pediatric residency at the University of Colorado School of Medicine, Denver,
and the State University of New York at Syracuse. He completed a fellowship in pediatric
gastroenterology and nutrition at Harvard Medical School and Massachusetts General
Hospital, both in Boston.

Address correspondence to Alan M. Lake, M.D., Johns Hopkins University School of

Medicine, Pediatric Consultants, 10807 Falls Rd., Suite 200, Lutherville, MD 21093. Reprints
are not available from the author.

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