Managing recurrent abdominal pain in children

Reassurance and a stepped approach to investigations can help kids with functional abdominal pain get the best outcomes.

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Recurrent abdominal pain of childhood, also known as functional abdominal pain, is very common, but it’s often self-limiting and rarely indicative of serious underlying pathology, says Dr Rupert Hinds, consultant gastroenterologist at Monash Children’s Hospital.

Despite this, the hurt is as real as a gut punch.

Functional abdominal pain is thought to be a disorder of gut-brain interaction. As such, it tends to affect sensitive children, Dr Hinds says.

“They’re often the kids who are really introspective. They’re often quite smart or high achievers at school.”

It also overlaps with anxiety, he says.

Children with this condition have a lower pain threshold, and as with IBS in adolescents and adults, tend to perceive normal gut sensations as negative. “We all get that gurgle, that noise, that gas, and we get on with it,” Dr Hinds says. “But in that IBS phenotype, it’s ‘Oh my goodness, what’s going on?’ So the cycle begins.”

Clinical presentation

The parent or child describes recurrent pain episodes that are not related to eating or defecation, mostly periumbilical, and often severe with associated pallor.

“Once the pain cycle starts these kids look a bit unwell,” Dr Hinds says. “Parents often say they’re pale. Sometimes they’re nauseated.”

Pain usually resolves spontaneously, and the child is well between episodes.

The condition mainly affects primary school-aged children, and these symptoms would be more concerning in younger kids. It is also more common in girls than boys.

Diagnosis and investigations

Diagnosis is primarily based on history and examination, but it’s important to screen for red flags or atypical features that may suggest more serious pathology. These include:

• age less than 5 years
• localised pain (not periumbilical)
• night pain
• dysphagia
• vomiting and diarrhoea
• change in bowel patterns
• any systemic features or growth concerns.

In children with no atypical features, Dr Hinds says a blood test for coeliac antibodies is the key initial investigation. He also recommends doing an FBE, CRP, LFTs, iron studies, and urine test.

If initial screening tests are concerning or abnormal, consider arranging additional tests and referral to a specialist, Dr Hinds says.

Ultrasound is one of the least useful investigations, he adds. While it may seem a logical choice, “the yield for this in every study ever done is really low”. Be particularly wary of mesenteric adenitis findings on ultrasound. “These are often post-viral and are almost never explanatory for chronic abdominal pain and equally are not concerning.”

Helicobacter pylori is rarely implicated, but worth considering if:

• pain is epigastric or postprandial
• there is a family history of peptic ulcers
• the child is from somewhere in the world where helicobacter is more common.

When warranted, Dr Hinds typically does H. pylori stool antigen testing in younger children and breath testing in older children.

Gastroscopy is not recommended unless there are worrying features such as epigastric or postprandial pain, vomiting or reflux. One US study showed that less than 10% of 1000 children with uncomplicated abdominal pain had positive endoscopic findings.

Overall, it’s important to avoid excessive investigations, so managing parental expectations is key.

“Explain to parents that a gazillion tests are not going to be helpful,” Dr Hinds says.

In fact, it can even make things worse, because it can lead parents to think “this doctor doesn’t know what they’re doing: they’ve done an ultrasound, now a gastroscopy, now a colonoscopy. When is it ever going to stop?”

“At some point, it’s hugely important to draw a line in the sand and say this is what it is.”

Differential diagnoses

Around 30% of school-age children experience constipation at some point, so be sure to rule this out. Dr Hinds recommends asking every child with chronic abdominal pain, rather than their parents, to explain what’s going on as best they can. Young kids can’t always articulate constipation problems, so ask specific questions like, “Is it hurting? Is it difficult? Can you get the poo out?” You might also palpate stool on examination.

Another important diagnosis to consider is abdominal migraine. It feels like a viral illness, so should only be considered after four or five episodes, Dr Hinds says. Symptoms include paroxysms of moderate to severe abdominal pain which may be accompanied by aura, headache, nausea, vomiting, or pallor.

“They will say ‘my tummy felt a bit weird when I went to bed’, and they often wake up in the middle of the night with abdominal pain or vomiting,” Dr Hinds says. Loss of appetite is also a feature.

“This is not the kid who wants to bunk off school and play on their iPad. This is a kid who is still stuck in bed by lunchtime, refusing even chocolate, lollies and their favourite drinks.”

Each episode lasts two hours to a few days and feels the same. Triggers are not always present, and the child is well between episodes. It may be associated with a family history of migraine.

Management

The mainstay of managing functional abdominal pain in kids involves breaking the pain cycle, Dr Hinds says.

Reassurance is key to that, and Dr Hinds offers some tips.

He says it’s important to make it clear to parents that you’re not disputing the reality of their child’s pain, but the cause is not serious.

It can be helpful to explain that sensitivity is part of the condition. For example, if the child’s mother has IBS, you could say, “You have a sensitive tummy like Mum does.”

He also suggests explaining how anxiety overlaps with functional abdominal pain, and recommends considering psychological strategies in particularly problematic and pervasive cases.

Key takeaways: Functional abdominal pain is very common in school-aged children and often self-limiting. Serious underlying pathology is rare. Investigations should be minimal and targeted in the presence of red flags. Management hinges on breaking the pain cycle through education and reassurance.

To hear more on this topic from Dr Rupert Hinds, register here for Healthed’s free webcast on 20 February.

Attendees will be eligible for:

• Attend the webcast and earn 2 hrs CPD in the Educational Activity category by attending the webcast lecture (RACGP & ACRRM approved)
• Complete the optional post-webcast quiz and earn 0.5 hrs CPD in the Reviewing Performance category (RACGP & ACRRM approved)
• Complete the optional Patient Case Review and earn a further 0.5 hrs CPD in the Reviewing Performance category (RACGP approved*)
• Undertake the optional Micro Audit and gain 1 hrs CPD in the Measuring Outcomes category (RACGP approved*)
  * We are working with the ACRRM to have the Patient Case Review (RP) and Micro Audit (MO) approved for its members as well, however ACRRM’s approval processes are somewhat slower! Until then, ACRRM members can claim the same CPD as last year. 
• Other professions can self-claim up to 4 hrs CPD. 
• Attendees will receive Certificate of Attendance approx. two weeks post-webcast.

Sophia Auld is a medical writer.