Chronic abdominal pain in children and adolescents – Children’s health

Chronic abdominal pain in children and adolescents
Author
Mariam R Chacko, MD
Section Editors
Amy B Middleman, MD, MPH, MS Ed
Jan E Drutz, MD
George D Ferry, MD
Deputy Editor
Mary M Torchia, MD
Disclosures

ABDOMINAL PAIN OVERVIEW — Chronic and recurrent abdominal pain is common in children and the term refers to pain for which a specific cause (by history, physical examination, or laboratory tests) has not been determined. It occurs in 9 to 15 percent of all children. In boys, pain is most common between ages 5 and 6 years. Girls have pain most commonly between 5 and 6 years and 9 and 10 years.

In most cases, abdominal pain is not serious and it gets better without treatment. However, when it is recurrent and a specific cause has not been identified, treatment can be a challenge. The pain can affect your child’s ability to have a normal life including attending school. This topic reviews treatment approaches that can help your child cope with the pain and/or help the pain go away.

A topic review that discusses abdominal pain in adults is available separately. (See “Patient information: Upset stomach (functional dyspepsia) in adults”.)

ABDOMINAL PAIN CAUSES

Organic disorders — Organic disorders include conditions caused by an identifiable problem in the body. Constipation is one of the most common causes of recurrent pain. (See “Patient information: Constipation in infants and children”.)

Other causes include stomach and intestinal problems (eg, heartburn, ulcers, lactose intolerance, parasitic infections) and muscle or bone pain. Less common causes include urinary tract infection and inflammatory bowel diseases (eg, Crohn’s disease, ulcerative colitis). In menstruating and sexually active adolescent girls endometriosis and sexually transmitted infections, respectively, need to be considered.

Signs and symptoms — Features that suggest an organic disorder depend upon which disorder is present, but may include one or more of the following:

Pain that awakens the child
Significant vomiting, constipation, diarrhea, bloating, or gas
Blood in the stool
Unintentional weight loss or slowed growth
Changes in bowel or bladder function
Pain or bleeding with urination
Abdominal tenderness
Functional disorders — Functional disorders do not have an identifiable cause. Examples include functional dyspepsia (stomach upset), irritable bowel syndrome (IBS), abdominal migraine and functional abdominal pain. The symptoms can be so severe that the child may have frequent absences from school and be unable to participate in activities.

Functional dyspepsia — Dyspepsia is pain or discomfort in the upper belly. Discomfort may include feelings of stomach fullness, becoming full after eating a small amount of food, bloating, nausea, retching, or vomiting.

Irritable bowel syndrome — Irritable bowel syndrome (IBS) causes symptoms including chronic abdominal pain and a change in bowel habits (diarrhea or constipation or both). (See “Patient information: Irritable bowel syndrome”.)

Abdominal migraine — Abdominal migraines cause episodes of intense abdominal pain, centered in the mid-abdomen, lasting one hour or more. The child might also have nausea, vomiting, headache, or sensitivity to light. Many, but not all, children with abdominal migraine have a family history of migraine. (See “Patient information: Headache in children”.)

Functional abdominal pain — Some children have symptoms that do not fit the definition of organic disorders, functional dyspepsia, IBS or abdominal migraine. In this case, the child might be described as having functional abdominal pain.

The pain may be difficult to describe and locate
It is usually unrelated to meals, activity, or bowel movements
The pain may occur with other symptoms, such as nausea, dizziness, headache, and fatigue
Pain typically lasts less than one hour
Most children do not have problems with growth, weight loss, fever, rash, joint pain, or swelling
Many children with functional abdominal pain have a family history of digestive problems
Functional abdominal pain is often triggered by stress or anxiety. This can happen during periods of change or stress in families (such as the birth of a new sibling, family member’s illness), when the parent(s) has limited time to spend with their child. Starting school may also trigger recurrent abdominal pain. In some cases, a child can develop chronic abdominal pain related to his or her need for attention.

Your response to your child’s pain can reinforce the child’s behavior. For example, if you show that you are worried about your child’s pain, the child may become more anxious, and the pain may worsen. If instead, you pay attention to the child’s other activities, this might satisfy the child’s need for attention and reduce the child’s abdominal pain. (See ‘Positive attention’ below.)

ABDOMINAL PAIN DIAGNOSIS — To determine the cause(s) of abdominal pain, the child’s doctor or nurse will ask questions about the child’s medical history. You can prepare for these questions by reviewing the table (table 1). The doctor or nurse will also perform an exam. Blood tests are sometimes needed if there are signs of an organic disorder.

Pain diary — A pain diary is a way to keep track of a child’s pain during his or her usual daily activities. Typically, you record over the course of one week (including a weekend). At the end of each day, you or the child records information about the day’s pain (figure 1), including:

How bad the pain was (using a 1 to 5 or faces pain rating scale) (figure 2)
When pain occurred
If the pain prevented activities (school, sports, play)
Where the pain was
Possible triggers (food, activities, stressors, thoughts, feelings)
How long the pain lasted
If anything helped the pain go away
You can review the pain diary with the doctor or nurse at the next office visit. Pain that tends to occur only during school hours or only at home suggests a functional disorder. However, some children with chronic abdominal pain of childhood have pain during fun activities as well.

ABDOMINAL PAIN TREATMENT — If the initial evaluation suggests an organic disorder, the likely causes of pain will be investigated and a treatment plan will be developed.

However, chronic abdominal pain in children is most often caused by a functional disorder. There are a variety of treatments that can be helpful, but no single treatment is best. Thus, most experts recommend trying several treatments. This may require several visits with the doctor or nurse, especially if pain has been a problem for a long time.

The first goal of treatment is to help the child return to normal activities. A second goal is to improve the child’s pain. However, it may take some time to figure out what is causing the pain and find the best treatment. Thus, another important aspect of treatment is for the child’s doctor or nurse to help you and your child cope with pain. Finally, a functional disorder does not mean that the child does not have pain or that it’s “all in their head”.

Towards this goal, it is important for parents to build a good relationship with the child’s doctor or nurse. This will allow the doctor or nurse to explore stressors, try various treatments, and continue his/her evaluation when necessary.

Although functional abdominal pain can be triggered or reinforced by a desire for attention, it is rare for a child to “fake” pain. Acknowledge that the child’s pain is real and offer sympathy, support, and reassurance. But also take care to avoid reinforcing the pain by giving it undue attention.

Abdominal pain and stress — Stress can worsen pain, whether the source is functional or organic. Children with chronic pain can be depressed or anxious as a result of their pain and their efforts to get relief. Many children benefit from relaxation and behavioral therapies to address these aspects of their pain.

Positive attention — During periods of change or stress in families, it can be hard to spend enough time with your child. In some cases, the child will develop chronic or recurrent abdominal pain related to his or her need for attention. It may be helpful to schedule time every day that is devoted solely to the child. Scheduled time (positive attention) is preferable to time spent together when the child complains of pain (negative attention).

Relaxation techniques — Older children and adolescents with functional abdominal pain can learn brief muscle relaxation techniques such as deep breathing exercises. These techniques should be performed for 10 minutes at least twice every day, and can also be used during times of pain (table 2). A family member can act as “coach” if necessary (provided this attention does not provide positive reinforcement for the pain, as described above).

Behavioral therapies — Behavioral therapies may be recommended for children or adolescents with functional abdominal pain that has severely impacted activities of daily living. Cognitive-behavioral therapy, hypnosis, biofeedback, and psychotherapy help to reduce a child’s anxiety levels, help them to participate in normal activities, be involved in their treatment, and help the child better tolerate the pain.

A therapist or counselor can listen to the child and provide encouragement while preventing the child from withdrawing from important activities such as school. This type of treatment is most likely to be successful in children who have pain related to stress, but it is a good option for anyone with chronic pain.

Older children and families are often resistant to the idea of behavioral therapies. However, seeing a therapist does not mean that the child’s pain is not real or that it’s “all in their head.” A therapist can help the child and family to cope with the pain and support the child’s transition back into normal activities (eg, school).

Dietary changes — Studies have not shown that making changes in the diet are helpful for children with chronic abdominal pain. However, the following changes might be helpful in selected children.

Lactose — Lactose is a type of sugar found in milk and milk products (table 3). Children who are lactose intolerant often have symptoms of cramping pain, bloating, or gas related to eating or drinking lactose-containing products.

A lactose-free diet can help to ease these symptoms; this is done by eliminating milk and milk products or by using lactase enzyme replacements (eg, Lactaid® milk or Lactaid® drops). If abdominal pain does not get better after two weeks, the child can restart milk and milk product. There also are tests for lactose intolerance, which can be used if the diagnosis remains uncertain.

Fiber — Eating high-fiber diet might improve symptoms in children who have constipation. In children who are afraid of moving their bowels (stool withholding), a “clean out” treatment is often recommended before adding fiber to the diet. (See “Patient information: Constipation in infants and children”.)

Other changes — In some children, there are foods, drinks, and medicines that make symptoms worse. Common triggers include:

High-fat foods
Caffeine
Foods that increase gas (beans, onions, celery, carrots, raisins, bananas, apricots, prunes, Brussels sprouts, cabbage, cauliflower, broccoli, asparagus, wheat germ) (see “Patient information: Gas and bloating”)
Medicines that can cause upset stomach include non-prescription pain medicines, such as aspirin and ibuprofen (sold as Advil®, Motrin®).

Medicines — Medicines might be needed for some specific causes of abdominal pain. Talk to your child’s doctor or nurse before trying medicines.

WHEN TO SEEK HELP FOR ABDOMINAL PAIN — Parents of children with chronic or recurrent abdominal pain who also have the following signs or symptoms should call their healthcare provider immediately:

Bloody stools, severe diarrhea, or recurrent vomiting.
Abdominal pain that is severe and lasts more than one hour, or severe pain that comes and goes and lasts more than 24 hours.
Refusing to eat or drink anything for a prolonged period.
Fever higher than 102ºF (39ºC), or fever higher than 101ºF (38.4ºC) for more than three days. The table describes how to take a child’s temperature (table 4).
Pain when urinating, needing to urinate frequently or urgently.
Behavior changes, including lethargy or decreased responsiveness.
Parents should call the healthcare provider during office hours if the following symptoms develop, or if they have general concerns about their child’s abdominal pain:

Chronic constipation (having less than two to three bowel movements per week)
Loss of appetite, weight loss, or becoming full after small amounts of food
WHERE TO GET MORE INFORMATION — Your child’s healthcare provider is the best source of information for questions and concerns related to your child’s medical problem.

 

Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient Level Information:

Patient information: Upset stomach (functional dyspepsia) in adults
Patient information: Constipation in infants and children
Patient information: Irritable bowel syndrome
Patient information: Headache in children
Patient information: Gas and bloating

Professional Level Information:

Emergent evaluation of the child with acute abdominal pain
Evaluation of the child and adolescent with chronic abdominal pain
Management of the child and adolescent with chronic abdominal pain

The following organizations also provide reliable health information.

National Library of Medicine
(www.nlm.nih.gov/medlineplus/healthtopics.html)

The University of Michigan Child Development and Behavior Resources
(www.med.umich.edu/1libr/yourchild/)

 

REFERENCES
Baber KF, Anderson J, Puzanovova M, Walker LS. Rome II versus Rome III classification of functional gastrointestinal disorders in pediatric chronic abdominal pain. J Pediatr Gastroenterol Nutr 2008; 47:299.
American Academy of Pediatrics Subcommittee on Chronic Abdominal Pain. Chronic abdominal pain in children. Pediatrics 2005; 115:812.
Huertas-Ceballos A, Logan S, Bennett C, Macarthur C. Psychosocial interventions for recurrent abdominal pain (RAP) and irritable bowel syndrome (IBS) in childhood. Cochrane Database Syst Rev 2008; :CD003014.
Boyle JT, Hamel-Lambert J. Biopsychosocial issues in functional abdominal pain. Pediatr Ann 2001; 30:32.
Crushell E, Rowland M, Doherty M, et al. Importance of parental conceptual model of illness in severe recurrent abdominal pain. Pediatrics 2003; 112:1368.
Huertas-Ceballos A, Logan S, Bennett C, Macarthur C. Dietary interventions for recurrent abdominal pain (RAP) and irritable bowel syndrome (IBS) in childhood. Cochrane Database Syst Rev 2008; :CD003019.
Weydert JA, Ball TM, Davis MF. Systematic review of treatments for recurrent abdominal pain. Pediatrics 2003; 111:e1.