Recurrent Abdominal Pain In Children

Abdominal pain in the child that recurs regularly is a common problem for general practitioners and paediatricians. It is one of the most difficult consultations due to the parental concerns about a possible serious cause.  Parents maybe concerned about serious gastrointestinal disorders, food intolerances, or other generalised illnesses. They may have received ill informed advice from relatives, friends and the internet. In most instances there is no simple explanation for recurrent abdominal pains and extensive investigations are frustratingly normal. A careful history and examination is often all that is needed to ensure a serious cause is not missed. The best way of approaching this is to discuss the likely medical causes and those that do not have an identifiable cause.  But first we will look at constipation as this is common.

Constipation

The definition is pain and discomfort when passing a bowel action. Young children for a variety of reasons can have a period of constipation, and they will suffer intermittent abdominal pains. This often occurs at the start of prep or grade one, where ‘bowel routines’ are put aside, due to being too busy, having to use unfamiliar or public toilets, and sometimes diet related.  The history is a 4- 7 year old child who has recurrent abdominal pains, and passage of hard bowel actions at times. They are otherwise healthy, may be bedwetters, and have no other significant symptoms. Some time spent toilet sitting and some simple dietary adjustment is all that is needed in the majority. Some children will need a little more encouragement and a period on stool softeners. See section on constipation and encopresis for more information.

Medical Causes of Recurrent Abdominal Painshutterstock_125563262

This represents a quite small percentage of children who present with recurrent abdominal pain. These children will have other symptoms which doctors will sometimes call ‘red flags’  and need to be asked about when discussing abdominal pain in children.

RED FLAGS

  • Weight loss
  • Significant loss of appetite
  • Bloody bowel actions
  • Night waking due to the pain
  • Vomiting

If these symptoms are present, particularly if there is more than one then investigations are warranted to rule out a significant medical cause.

  • Coeliac Disease – Although recurrent abdominal pains are a feature of coeliac disease, other symptoms are usually more important such as diarrhoea, bloating, weight loss and irritability. The diagnosis requires an endoscopy after a blood tests suggests this is the problem.  For more information go to separate article on coeliac disease. Many parents will be told that gluten intolerance is the cause of recurrent pains and this is generally false information
  • Inflammatory Bowel Disease – This is a rare and quite serious cause of recurrent abdominal pain. The child maybe particularly unwell, or may simply have pains and weight loss. Inflammatory bowel disease is an autoimmune disorder, where the bodies immune system will attack ‘normal’ bowel tissue, resulting in damage and inflammation. This causes abdominal pains, weight loss, bloody diarrhoea, and sometimes fever, lethargy and even dehydration. Blood tests and faeces examination is used to help diagnose and it is managed by paediatric gastroenterologists.
  • Food intolerance –   Strictly speaking, not really a disease, intolerance means that a certain component of the diet results in some gastrointestinal symptoms. We can all have food intolerance if we consume ‘too much’ of something. But here is a list of the more common diagnoses and what they mean.
    • Lactose intolerance is the most common, and presents as recurrent abdominal pains, gaseous loose bowel actions, particularly after having dairy foods. This condition is common in Asians but is seen in all races.  It is the result of the small intestine not having enough ‘lactase’, which is the enzyme responsible for breaking down lactose. When this is dumped in the large intestine then bacteria will ferment the lactose resulting increase gas production and organic acids causing diarrhoea. Cutting out excess lactose will help symptoms.
    • Irritable Bowel  – This is a very real condition in adults and those who suffer from it will often say it began in childhood. Symptoms include bloating, abdominal discomfort, and bowel actions that vary in frequency and consistency. The usual culprits include complex sugars which end up being fermented in the large intestine similar to lactose intolerance. Polyols, fructans, fructose, disaccharides to name a few and recently the FODMAPS diet designed by Sue Shepherd an Australian dietician has become accepted as an excellent approach to IBS.
  • Reflux and dyspepsia – Some children will develop recurrent abdominal pain that is just under the diaphragm, maybe improved with food, and can wake them at night. Some will complain of reflux of food or stomach contents into their throat. They are well otherwise but at times appear distressed with the discomfort. This can sometimes be a short term complaint that settles with reflux medication and does not recur, but if it persists will need to be evaluated by a paediatric gastroenterologist.
  • Other Medical Causes.  The medical textbook is filled with rarer causes of abdominal pains, but they will be always associated with other symptoms, suggesting the diagnosis. However it is worth discussing a few as many parents ask about these during the consultation
    • Tumours – naturally some parents will worry that these unexplained symptoms may represent something serious like cancer. Abdominal tumours do exist but obviously are rare. Symptoms will dramatically increase over a short space of time, (weeks), with weight loss, abdominal discomfort, night waking, vomiting and is clear something serious is wrong.
    • Bowel obstruction/twisted bowel – for some reason this comes up quite often as a possible cause but these kind of conditions do not present as recurrent  abdominal pain.  They will present as profuse bile stained vomiting and pain that clearly needs emergency surgery.
    • Food allergy – an allergic reaction to a food involves an immediate immunological reaction. Usually this takes the form of  rash, lip swelling, feeling feint, cough and choking sensation, and vomiting. Allergy does not cause recurrent abdominal pains.

Non Medical Causes of Recurrent Abdominal Pain 

The discussion below represents about 80% of the cases of recurrent abdominal pains seen by general practitioners and paediatricians. It can be frustrating for concerned parents who worry about significant disease and are hoping for extensive ‘tests’ to find out the cause. When it is clear that ‘doctors’ don’t seem to be able to help, parents will often turn to alternative practitioners to try and get some answers. These children will have normal growth, normal appetite and weight gain, the pain will not wake them during the night, and there is no vomiting and bowel actions are normal. In other words they are medically healthy.

Anxiety related abdominal painshutterstock_180226805

Children who tend to be anxious will often complain of abdominal pain at various times. The gut is intricately linked with the brain, using similar chemicals, and often during periods of stress, or over excitement gastrointestinal symptoms occur. An example is the ‘butterflies’ that people experience prior to doing something ‘nerve-wracking’ such as speaking in public. Children will often divert anxieties and worries to abdominal discomfort. An example is the anxious child who worries about school. During school they experience discomfort enough to keep them from going to school, but during the holidays the symptoms disappear. The child is not ‘making it up’, they do feel abdominal discomfort, but this is not due to any particular medical cause. Helping them with the anxiety and sometimes seeking professional help will often lessen these episodes.

Non Specific Recurrent Abdominal Pain

This represents a large  proportion of children who attend general practice for abdominal pains.  The age range is between 5 and 10 years, the pains will occur several times per week, there is no relationship to behaviour, diet, or activity. Sometimes the child will simply complain of pain and continue with their activities, and sometimes the child will lie down or hold their abdomen for a short while. The pains do not last particularly long and there is no obvious explanation. It is not related to bowel actions, though sometimes going to the toilet will help.

The pains will come and go for a number of months, and may return after a break of several months.  This is very similar to headaches, further suggesting the brain gut link. Usually by early puberty they will abate and settle.

When examined, the child will clearly be well, there is no tenderness on feeling the abdomen, and the general growth parameters and rest of the examination is normal. The most important aspect of the examination is to ensure an accurate weight. If in a months time the weight is increased or the same that helps to reassure that there is no sinister cause.

It is hard to know exactly what is causing this discomfort but studies imply that some people are more sensitive to the normal ‘groans and moans’ of the gastrointestinal tract than others

What about doing some tests ?

Parents and even doctors worry about ‘missing something’ such as the medical causes listed above. Sometimes some simple tests provide reassurance that there is no sinister cause.  Test include may include faeces tests, blood tests and imaging such as ultrasound.

  • Faeces tests include looking for infections such as giardia or blastocystis. These are sometimes responsible for abdominal pains and are easy to treat.
  • Blood tests – Full blood count and inflammatory markers such as an ‘ESR’  will rule out conditions such as inflammatory bowel disease. Sometimes if there is a family history or the parents strongly feel coeliac disease might be a cause it is reasonable to add coeliac serology.
  • Abdominal US –  The best thing about an abdominal US is that is relatively easy to perform, has no side effects and is painless. It is nearly always normal and so this can be very reassuring to parents worried about something serious. The US does not show the inside of the gastrointestinal system, but it does show that all the anatomy, such as the liver, the spleen, the kidneys are all in the right place and are the right size.

A plain X-ray of the abdomen is generally not recommended as it is an unnecessary dose of radiation and it does not yield much information.  It is very occasionally used in managing long term constipation but this is going out of favour.

Other tests are the domain of specialists such as paediatric gastroenterologists. These include a camera looking into the stomach (endoscopy) or a colonoscopy.  These would only be performed if there were significant other symptoms.

How Should Parents Manage Recurrent Abdominal Pains

If it is clear after assessment and investigations that the diagnosis is not serious management is similar to how you would manage a headache.  Often the pains are mild and the child can continue life as normal. Encourage school and sometimes give simple analgesics. Keeping a diary of the episodes is sometimes useful, as if there is a significant increase in frequency or severity then a reassessment is needed. Distraction by keeping the child busy is often all that is needed.

 

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