Chronic abdominal pain in children

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

a. This chapter focuses on children with abdominal pain, not babies. You can find an excellent chapter about irritability and abdominal pain in infants in a different part of this website, in the following link.
b. This chapter discusses children who seem to suffer from abdominal pain all the time—not healthy children who wake up one day with severe abdominal pain or 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’s important, what isn’t, and what to look out for. We won’t be discussing specific diseases in this chapter.

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

The truth is, we don’t really have a definitive answer.
What we do know is that the answer is “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’s very important to distinguish between functional abdominal pain and organic causes of abdominal pain.
Functional abdominal pain – recurrent abdominal pain without a known cause or underlying medical disorder (more on this below).
Abdominal pain of organic cause – pain with a clear medical explanation.
Note: A child with functional abdominal pain can experience just as much pain as one with an organic cause.
The art of medicine lies in listening to the child’s story, using clinical judgment, conducting tests (only if needed), and finding the right way to help—regardless of the type of pain.
That’s exactly what we’ll explore in this chapter.

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

Family history – Every case is different. But if a parent has inflammatory bowel disease, this is significant and may warrant further evaluation. A sibling with celiac disease (read more here) also means that other siblings should be screened.
Child’s age – Age has a big impact. The causes of chronic abdominal pain vary across age groups. This chapter does not address infants under one year. Even for older children, different ages may require different approaches. Chronic abdominal pain in children under four is often considered a red flag.
Pain characteristics and location – Is it sharp or dull? In the umbilical area or elsewhere? Does it last seconds or minutes? Is it linked to eating? Does it wake the child from sleep? Each of these factors helps guide the approach.
Growth and development – One of the most important factors. A child who is growing and gaining weight normally is very different from one who has lost weight in the past six months. Both might need testing, but weight loss raises stronger concern for an underlying issue.
Associated symptoms – Does the child have vomiting, diarrhea, constipation, poor appetite, bloody or mucousy stools, rashes, mouth ulcers, or joint swelling?
Physical examination – Every child with recurrent abdominal pain must be examined by a pediatrician, including a full abdominal exam.

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

In medicine, a “red flag” refers to a sign or symptom that requires thorough medical evaluation. Red flags for chronic abdominal pain in children include:
– Age under 4 years
– Weight loss
– Recurrent vomiting
– Recurrent diarrhea, especially bloody or mucousy
– Jaundice
– Edema
– Prolonged or recurrent fever
– Family history of inflammatory bowel disease, celiac disease, or Familial Mediterranean Fever
– Enlarged liver or spleen (detectable on physical exam)
– Back pain or hip pain radiating to the shoulders
– Pain that wakes the child from sleep
– Elevated inflammatory markers such as white blood cell count (more info here), CRP, or ESR

What role does the pediatrician play in the evaluation of abdominal pain in children? When should a pediatrician be consulted?

Every child with recurrent abdominal pain must be evaluated by a physician.
The pediatrician will take a thorough history and decide—together with the parents—whether further testing is needed.
If the history points clearly to functional pain, excessive testing should be avoided, as it may reinforce the focus on pain. Distraction and minimizing attention to the pain are important parts of treatment.
If tests are needed, they may include blood work, imaging (such as ultrasound), or other studies.

What types of lab tests are relevant when evaluating abdominal pain in children?

It’s hard to cover all possibilities. Some children need no tests, while others may require advanced testing (e.g. for Familial Mediterranean Fever).

But what are the basic tests to be aware of?

Complete blood count – a routine test. Learn more here.
Full biochemistry panel – includes electrolytes and liver function.
Celiac antibodies – may show up in functional pain but don’t always indicate the cause.
Inflammatory markers – depends on the physician. Most commonly CRP, sometimes ESR.
These are standard venous blood tests—not finger pricks.
Urine test – if the doctor feels it’s needed.
Stool test – especially with frequent diarrhea. This may include bacterial culture, parasite screening, or PCR testing (more here).
Fecal calprotectin – used only with a gastroenterologist’s referral, when inflammatory bowel disease is suspected.

What imaging tests are used to evaluate abdominal pain in children?

If imaging is needed, ultrasound is the first choice.
It’s simple, radiation-free, and gives a lot of useful information.
X-rays, CT scans, or MRIs are rarely needed and only ordered by specialists in specific cases.

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

There are many, ranging from endoscopies and colonoscopies to capsule endoscopies (swallowing a small camera).
Other options include testing for helicobacter pylori.
After the initial evaluation, any decision to pursue further testing should be made with a pediatric gastroenterologist.

So, what is functional abdominal pain?

As explained earlier, this is abdominal pain without a physical or medical cause.
It may be difficult to understand how real pain can exist without a clear source. One theory is hypersensitivity in the nerve pathways between the intestines and brain—pain signals are sent even when nothing is wrong (like a car alarm going off from the wind).
In children, emotional stress and anxiety often express themselves through abdominal pain.
There are no specific tests that can confirm or rule out functional abdominal pain. But this is not merely a diagnosis of exclusion.
We don’t need to perform every possible medical test to reach this diagnosis. Instead, we should take a good history, examine the child, consider limited testing if needed, and confirm functional abdominal pain based on clinical findings.

How is functional abdominal pain treated?

Once confirmed, treatment is behavioral and based on distraction.
Often, parents notice that when their child is busy with something enjoyable, the pain disappears (the pain is still there, but the child doesn’t notice it).
It’s very important not to cancel activities or school. Doing so reinforces the pain.
Avoid focusing on the pain or asking about it constantly. Medical tests and frequent discussions about the pain should also be minimized.
If needed, techniques like guided imagery, biofeedback, or hypnosis may be helpful—even without a diagnosed psychological issue.

How are organic causes of abdominal pain treated?

That depends entirely on the cause.
Reaching the correct diagnosis is key—whether it’s constipation (read more here) or peptic ulcers, each has its own treatment.

In summary, this is a basic yet important chapter, designed to help parents understand the reasoning behind how physicians investigate recurrent abdominal pain in children.
Hopefully, this knowledge will empower you in your next visit to the pediatrician—helping ensure your child receives the best possible evaluation and care.