Chronic abdominal pain in children

But before we begin, it is important to keep in mind the following three concepts:

a. This chapter focuses on children with abdominal pain, not babies. You can find a fantastic chapter about irritability and abdominal pain in infants in a different part of this website, in the following link.
b. This chapter will be discussing children who seem to be suffering from abdominal pain all the time. Not a healthy child, that wakes up on a random day with severe abdominal pain or with diarrhea.
c. The purpose of this chapter is to give you, the parents, the tools to understand the approach to chronic abdominal pain in children. What is important, what isn’t and what you should be looking out for. We will not be discussing specific diseases in this chapter.

How common is to hear “my tummy hurts” in children? And what does chronic abdominal pain mean?

The truth is that we don’t really have an answer to this question.
I think that we are all aware, that the answer to this question is simply “very common”.
In fact, most children complain of abdominal pain here and there, quite frequently.

What are the two most important types of chronic abdominal pain in children?

It is very important to distinguish between functional abdominal pain and organic causes of abdominal pain.
Functional abdominal pain – recurrent abdominal pain without a source, without an underlying medical disorder. More to follow.
Abdominal pain of organic cause – abdominal pain that has a clear medical cause.
Note that a child with functional abdominal pain can experience just as much pain as one suffering from pain with an organic cause.
But the art of medicine is to listen to the child’s story, use your wisdom, carry out available tests (only if necessary), and provide a solution to the complaints, regardless of the type of pain presented.
And this is what we are going to learn to do in the following chapter.

What are important aspects to consider when it comes to taking medical history for abdominal pain?

Family history – again, every case is individual. However, if one of the parents has inflammatory bowel disease, for example, then this is a piece of information that requires reassessment of the child if they are suffering from recurrent abdominal pain. A sibling with celiac disease (more about celiac in this link) calls for celiac screening in the remainder of the siblings, as well.
The child’s age – the child’s age has tremendous impact because the causes of chronic abdominal pain in children varies depending on the age group. Once again, this chapter will not be discussing abdominal pain in infants under the age of one, but even when considering older children, the approach and investigations required vary depending on age group. It is worthwhile noting that chronic abdominal pain in children under the age of four, is often referred to as a red flag, as you will see below.
The characteristics and location of the pain – is the pain sharp? Dull? Is it in the umbilical area or elsewhere in the abdomen? Each one of the different areas will be approached differently by the physician, as you will see below. In addition, does the pain last for a few seconds or minutes? Is it associated with eating? Does it wake the child up from sleep?
Normal growth and development – these are one of the most important things we need to be looking for. There is a big difference between a healthy and well-developed child, that is gaining weight well, and between a child that has involuntarily lost weight within the past six months. It is possible that both of these two different presentations will require investigation, but it is obvious to all of us that the child who has lost weight is more likely to have an underlying disorder that we shouldn’t miss.
Accompanying symptoms – does the child have diarrhea? Vomiting? Constipation? Decrease in appetite? Are their stools bloody or have mucous? Any rashes? Aphthous ulcers? Swelling in the joints?
Normal physical examination – every child complaining of recurrent abdominal pain must undergo a full physical examination by a pediatrician, including an abdominal examination.

What signs are considered red flags when investigating recurrent abdominal pain in a child?

A red flag is an important term in medicine, and it is used to refer to a sign or symptoms presented by a patient that must require a full medical assessment.
So clearly, this varies depending on the presentation. But the red flags for chronic abdominal pain in children are:
# Age less than 4 years
# Loss of weight
# Recurrent episodes of vomiting
# Recurrent diarrhea, including bloody diarrhea or diarrhea with mucous
# Jaundice
# Edema
# Prolonged fever or recurrent febrile episodes
# A family history of Inflammatory Bowel Disease, Celiac or Familial Mediterranean Fever
# Enlarged liver or spleen – if present, this will be detected by a physician on physical examination
# Back pain or hip pain that radiates to the shoulders
# Pain that wakes a child up from their sleep
# Elevated inflammatory markers – abnormal white blood cell count (you can read more about this here), elevated CRP or elevated erythrocyte sedimentation rate (ESR)/

What role does the pediatrician play when it comes to the investigation of abdominal pain in children? When should a pediatrician be consulted?

Every child, regardless of their age, suffering from recurrent abdominal pain, must be seen by a physician.
The physician will take a medical history and will make a joint decision regarding the appropriate investigation (if required) together with the parents.
When the medical history is clear and suggests functional pain, it is best to minimize the number of investigations carried out, because these will only emphasize the abdominal pain, and as you will see below, distractions and putting minimal emphasis on the abdominal pain are an important aspect of treatment.
If a decision has been made to carry out an investigation, it may include laboratory work, imaging (such as abdominal ultrasound) and any other test.

What type of laboratory tests are relevant when investigating abdominal pain in children?

It is important to understand that it is very difficult to cover all the different available tests. Some children do not need to undergo any laboratory work while others need to be referred to genetic testing for Familial Mediterranean Fever, for example.

But what are the basic tests that you should be aware of?

Complete blood count – a routine blood test. What is its significance? Find out in this link.
A full biochemistry panel – a test tube that includes biochemistry as well as salts in the blood and liver function tests.
Antibodies for celiac disease – common also in functional pain but the pain is not necessarily caused by the disease.
Inflammatory markers – this is up to the physician’s discretion. The most common marker is CRP, but some prefer testing for ESR.
Of course, these tests are drawn from venous blood and not from blood taken by poking a finger.
Urine test – up to the physician’s discretion.
Stool test – when a child has recurrent episodes of diarrhea, a stool test is usually taken as well. Bacterial stool culture, parasite testing or stool PCR for all the different pathogens (find out more about the difference between the classic stool cultures and PCR tests here).
Fecal calprotectin test – this is a test that is only performed following a gastroenterologist’s referral, and it is only done when inflammatory bowel disease is suspected.

What imaging tests are relevant when investigating abdominal pain in children?

There is no doubt that if imaging is required, the first choice is an ultrasound of the abdominal organs.
This is a simple test, free of radiation, and it provides the physician with lots of information about the abdominal organs.
X-ray, CT or MRI tests of the abdomen – these are usually not required except for very specific cases following a decision made by a specialist.

What additional tests can be performed to assess abdominal pain in children?

Once again, there’s no end to the tests available.
From endoscopies (a camera is inserted into the stomach through the mouth) to colonoscopies (a camera is inserted into the intestines through the anus). From helicobacter pylori testing to a capsule endoscopy, where the child swallows a small capsule containing a camera that records images as it travels through the gastrointestinal tract.
Therefore, following the initial investigation, and typically following consultation with a pediatric gastroenterologist, try to make a joint decision with regards to the next tests that need to be carried out, if any are to be carried out at all.

So, what is functional abdominal pain?

Functional abdominal pain, as we mentioned earlier, is abdominal pain without a medical source, without any underlying medical illness.
It is difficult to understand, or accept, that there is such a thing – real abdominal pain without a bodily cause. The leading theory is that it is caused by oversensitivity in the nervous system that connects the child’s intestines to their brain when pain signals are transmitted when there actually is no source for the pain (similar to a car alarm that goes off because of wind, without anyone breaking into the car).
In addition, in children, it is common to see anxiety finding a way to express itself through abdominal pain, and this is something that should always be considered.
There aren’t any medical exams that can confirm or rule out this type of abdominal pain. But it is important to understand that this is not just a diagnosis of exclusion. That means, we shouldn’t be diagnosing children with functional pain only after carrying out every single medical exam out there and failing to reveal any findings. The goal should be to listen to the child’s story, take their medical history and the history of their abdominal pain, examine them physically, consider the need for brief laboratory testing/ or imaging and afterwards to confirm the diagnosis of functional abdominal pain and find relief for their pain.

How is functional abdominal pain treated?

Once functional abdominal pain is confirmed, the treatment is behavioural and is based on distractions. Many times, parents notice that when their child is occupied with a hobby they enjoy, they do not complain of abdominal pain (the pain is there, but the child does not notice it). It is very important not to cancel any activities, not to miss school days, and not to leave school early because of the pain because this will reinforce the pain.
Also, undertaking medical investigations or putting an emphasis on the pain (constantly asking the child whether they are in pain right now, or experienced pain during the day) are unwanted. If necessary, methods for distraction, such as guided imagery, biofeedback, and hypnosis, can be provided (psychologists believe these methods work even in the absence of psychological disorders).

How can organic causes of abdominal pain be treated?

Here, it all depends on the cause.
First of all, it is important to reach the correct diagnosis – constipation (find out more about this common condition here)? Pain caused by peptic ulcers? Obviously, each one of these conditions has its own treatment.

In summary, this is a basic and important chapter, and its purpose is to present to parents the language and logic behind investigations suggested for a child presenting with recurrent abdominal pain.
I hope these tools and this language will help you in your next encounter with the pediatrician, so that your child receives the most accurate workup and treatment suitable for them.