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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