Information
Editors
Recurrent Abdominal Pain in Children
Essentials
- Aetiological investigations of abdominal complaints can be carried out in primary health care.
- The most common diseases/conditions that need to be ruled out are coeliac disease and inflammatory bowel disease. Lactose intolerance should be excluded in school-age children.
- Indications for additional investigations (alarming symptoms) include, among others, abnormal findings on abdominal palpation, abdominal pain during the night, weight loss, recurring episodes of fever, recurring vomiting and dysphagia, deceleration of growth and (bloody) diarrhoea.
Definition
- Recurrent abdominal pain is defined as abdominal pain recurring over a period of at least 2 months and interfering with the child's normal behaviour.
Aetiology and differential diagnosis
- The most common cause of prolonged, recurrent abdominal pain is constipation Constipation in Children. Obtaining a history of constipation from a child or adolescent may be challenging; medication should be tried if the situation is unclear.
- In school-age children, the possibility of lactose intolerance Lactose Intolerance should be assessed by performing a dietary trial and, as necessary, a genetic test.
- Of inflammatory diseases of the intestinal mucosa, coeliac disease Coeliac Disease and inflammatory bowel disease (IBD) Inflammatory Bowel Diseases in Children should be considered. Do not hesitate to perform coeliac disease antibody and faecal calprotectin tests for the purpose of exclusion.
- For any patient with prolonged symptoms, basic blood count with platelet count, chemical urinalysis and abdominal ultrasonography (including the urinary tract) should be done once.
- Abdominal pain associated with food may be non-allergic (quite common; FODMAP carbohydrates) or allergic (rare after toddlerhood) Food Allergy and Hypersensitivity in Children. If the child drinks a lot of cow's milk or some other evident cause is suspected (remember xylitol!), try withdrawing that food for a while; this may bring temporary relief.
- With food elimination diets, it is important to keep in mind that in most cases complete, permanent elimination is not necessary and moderate amounts of suspected foods can be returned to the diet.
- Conditions to be considered in the differential diagnosis of upper abdominal pain include functional dyspepsia (occurring in children, as well) and, in children with severe upper abdominal pain, also biliary tract disorders.
- As the role of helicobacter as a cause of abdominal pain in childhood is unclear, routine testing (faecal antigen test) is not necessary and only targeted tests should be performed in patients fulfilling the criteria for eradication therapy Dupuytren's Contracture.
- After toddlerhood, (repeated) courses of a few weeks of proton pump inhibitors can be considered for patients with upper abdominal symptoms; their significance in infants has been found to be equal to placebo.
- Several underlying psychogenic factors for recurrent abdominal pain have been identified. Child's symptoms of anxiety or depression, parent's anxiety symptoms and parent's own pain history are the most typical factors. Broaching the topic of fear and anxiety with the child and his/her parents is recommended.
- Children do not have colon or gastric cancer; the fear of cancer should be discussed in the very beginning. Significant malignant diseases occurring in children (rare: lymphomas and blastomas) can very well be excluded by a complete blood count with differential and abdominal ultrasonography.
- Patients with the kind of alarming symptoms mentioned above should be referred for investigations in specialized care at an early stage.
- Any unusual abdominal pain (clearly located in an area other than the umbilical area, waking the patient up at night, abnormal finding on abdominal palpation) also warrants further investigations.
- In addition, extensive avoidance diets, prolonged use of analgesics and staying away from school or other significant psychosocial harms warrant referral.
Functional abdominal pain
- Functional abdominal pain means pain with no actual underlying disease but caused by distension of the intestinal wall which is experienced as pain. If pain due to distension recurs (particularly in association with certain psychosocial factors), it may become prolonged.
- Functional abdominal pain can be diagnosed if pain continuing for more than 2 months is not associated with any change in bowel function and not explained by any other disease. The diagnosis can be made in primary health care. Diagnostic investigations to rule out other diseases should be made as indicated by the symptoms.
- Abdominal migraine and dyspepsia, i.e. upper abdominal symptoms, are subgroups of functional abdominal pain. Abdominal migraine occurs in children with a genetic tendency to migraine, and the clinical picture is paroxysmal as it is in migraine. There may not be any headache but auras and nausea occur commonly in addition to severe abdominal pain.
- Abdominal pain associated with bowel function often occurs in children with constipation Constipation in Children, as well as in association with irritable bowel syndrome.
- The aim of treating functional abdominal pain is to manage the sensation of pain, not to eliminate the symptoms completely. It is important to apply individually chosen measures to ensure that the child can go to school. Psychoeducation of the family and the parents on functional pain is important. Playing down the sensation of pain is not helpful but, on the other hand, ‘rewarding' pain by special attention or special liberties does not promote recovery.
- Constant or long-term use of analgesics is not recommended. It may be warranted to consult specialized care to assess the need for treatment of chronic pain.
Prognosis and surveillance
- The prognosis of functional abdominal pain is best if the patient and the family understand the psychosocial frame of reference of prolonged pain.
- Studies have not shown extensive investigations in specialized care to be useful in the absence of a medical indication.
- According to surveys, 20-25% of Finnish children report having abdominal pain at times. According to an international systematic review, one in three children with prolonged pain still have symptoms 5 years later.
- One factor worsening the prognosis is a parental history of pain.
- Systematic comprehensive reassessment of a child with pain must be performed if the pain persists. Follow-up visits and modes of contact should be agreed on at an early stage. It is important to ensure that the child can go to school, making special arrangements, as necessary.
References
- Gieteling MJ, Bierma-Zeinstra SM, Passchier J et al. Prognosis of chronic or recurrent abdominal pain in children. J Pediatr Gastroenterol Nutr 2008;47(3):316-26. [PubMed]
- Ramchandani PG, Stein A, Hotopf M ym. Early parental and child predictors of recurrent abdominal pain at school age: results of a large population-based study. J Am Acad Child Adolesc Psychiatry 2006;45(6):729-736. [PubMed]