Recurrent Abdominal Pain in Children

Why Does My Child Have so Many Belly Aches----and What Can I Do?

Abdominal pain is one of the most common indications for children to be seen by their pediatrician, by a pediatric gastroenterologist (specialist that sees belly aches in children) or in the emergency room. However, the written guidance for parents trying to determine how to manage this situation is not that helpful. Even guidelines that have been written for physicians are unable to provide insight into this problem and a popular theme is that most cases are “functional”. A google search reveals that multiple children’s hospitals and national gastroenterology societies describe functional abdominal pain as non-organic pain, which means, “the pain is not caused by physical abnormalities”. What is the specialist, the pediatrician, the parent, or the child themselves to do with that advice? If there are no physical abnormalities, the parent is left with the impression that the child is making up the problem! 

Warning Signs Require Prompt Evaluation by a Physician

If a child has a sudden onset of significant pain, or if there are “warning signs” then that situation warrants prompt medical attention. Warning signs would include significant or recurrent vomiting, (especially if the vomit is yellow, green, red, or black), or diarrhea (especially if the bowel movements appear greasy or float, or has blood), significant blood with any type of bowel movements, fever, decreased appetite (especially with weight loss) and if your child appears ill. 

However, if your child has been complaining of abdominal pain for a while then the following suggestions can help guide your approach. If the following suggestions cannot help you to identify the cause or if the measures provided are unable to relieve the pain, then medical attention should be sought.     

Four Common Causes Account for Most Belly Aches in Children

In my 30 years of practice, I have found four patterns that are present in the vast majority of children with this complaint. They can be identified without any investigations, and can all be effectively addressed. I have seen many children who experience substantial recurrent pain, who are frustrated by their physicians and parents telling them “there is nothing serious going on”. These children are invariably very grateful when the etiology is identified and corrected, and they can resume normal childhood fun. 

Recognizing Constipation 

The first problem is constipation, which worldwide is estimated to be present in 6-45% of all children. A group of experts created the “Rome criteria” to formally define this problem. The child must have two or more of the following in the last three months: Less than 3 bowel movements per week, hard stools, straining, incomplete defecation, the feeling of inability to pass stools, or the need for manual maneuvering to pass stools at least ¼ of the time. I would add other features to this list and even if a child has only one of these, correcting constipation will help. The pain is usually in the lower abdomen, left more than right, and often by the belly button. There is often pain with defecation, blood noted around the stool or on the toilet paper, very large bowel movements, or alternatively small little pellets as the predominant stool (even if they happen daily). There is usually bloating or distension or gas and the pain is often, but not necessarily always, decreased by defecation. Sometimes loose stools that can leak out, called encopresis, (for which some poor kids are referred to psychiatrists) and in some children, painful urination or recurrent urinary tract infections, can be the only clue. 

Treating Constipation

There are two phases to effective therapy. Initially, the old, hard stools have to come out. This usually takes several days and requires either a series of enemas or an oral purge. In order to prevent constipation from returning there needs to be a change in the diet (a dramatic increase in fluid and fiber) and behavior modification therapy (sitting on the potty with feet on a solid surface and blowing on a balloon to create a Valsalva 30-60 minutes after breakfast and after dinner). It is important to realize that a child with constipation will either stay with this problem, wind up on an endless cycle of medication, or modify their lifestyle as described above. 

Recognizing Pain Caused by Gastric Acid

Acid peptic disease which includes heartburn (also known as gastroesophageal reflux), gastritis, duodenitis, or ulcer and can be seen in more than 25% of children. Severe symptoms as listed above would warrant an investigation, often an upper endoscopy and biopsy, to understand the extent of the problem and identify causes. The main clues are pain after eating and at night, especially if the child wakes up with the pain but does not appear ill, decreased appetite, leaving meals (or bottles for infants) before finishing, occasional emesis (vomiting), and the symptoms of heartburn. Heartburn symptoms include regurgitation (tasting emesis in the mouth), bad or sour taste in the mouth, clearing of the throat repeatedly, and pain in the throat or chest with or without abdominal pain in the upper regions. Sometimes the only symptoms could be the consequences of the reflux, which can include persistent year-round nasal congestion, red throats without strep throat, repeated earaches or ear infections, hoarseness, or multiple dental caries resulting from the acid compromising the enamel of the teeth. 

Managing Acid Related Injury

If there is anyone in the family with a history of ulcer, or if the child is from an area with a high prevalence of ulcers, start by testing the stool for Helicobacter pylori antigen and consider eradication if present. Similarly, if the child is taking Advil, Motrin, aspirin, or other NSAIDs (nonsteroidal anti-inflammatory drugs) for headaches, joint aches, or menstrual cramps they should be eliminated, or at least minimized, and if possible exchanged for acetaminophen. All of these acid-related problems can be addressed with over-the-counter medicines such as H2 receptor antagonists or a short course of proton pump inhibitors. Liquid preparations are available for younger children or those who cannot swallow pills. (Virtually all school-aged children can be “trained” to swallow pills once their fears are recognized and addressed). If repeated administration is necessary, then the child should be investigated as suggested above.  

Recognizing that Irritable Bowel Syndrome (IBS) is Common in Children 

The third problem is the most elusive to diagnose and treat and occurs in about 15% of the population, or about 5 children in a class of 30. The Rome criteria for this diagnosis require abdominal pain at least 1 day per week for at least three months that is associated with a change in the number or consistency of bowel movements. I describe IBS to patients and their families as follows. Everyone has periods of the day when their intestines distend to allow stools to pass through on their way out. Patients with IBS have two features that lead to pain. They typically will have more distension than the 6 out of 7 children without IBS, and most importantly they are more sensitive to even slight degrees of distension. There can be forms with mainly loose stools (diarrhea) or constipation. The goal is therefore minimizing gas.

Helping the Child with IBS

I start by asking the children what foods have bothered them and remove them from the diet. I also arbitrarily remove unhealthy foods that potentially can cause excessive distension such as junk food, fast food, greasy foods, chips, sugary foods (candy, cookies, and cakes), and lactose-containing milk. If there is constipation, I add the features mentioned above. The first three to four weeks is strict avoidance. This usually allows the child to reach a point where they can experience a week or so of regular bowel movements and no pain. That becomes the biggest motivating factor for them to continue with the diet. Then small amounts of foods are slowly added back to the diet and their tolerance is determined. The goal is identifying what amount of food, (eg ½ slice of pizza, 3 chicken nuggets), a child can enjoy without symptoms. One tricky part is that a child on vacation, going to the beach, playing all day long, and generally enjoying his or her social situation with little stress will be able to tolerate certain amounts of foods without symptoms. The same child can have substantial trouble eating exactly the same amounts of the same foods, when they are studying for their final exams, not getting quite enough sleep or exercise, or having any other stressful family, social, or school situations in their lives. 

Children Can Have Two Separate Causes of Abdominal Pain at the Same Time 

As can be seen from the above prevalence numbers, these first three problems are not rare conditions for children to experience. I have seen many children for fourth, fifth, and sixth opinions that come in with stacks of medical records, test reports, and x-ray films hoping that I will find the rare disease that no other doctor can identify. These children actually have two of the above three conditions. When a doctor diagnoses one and treats it properly, the other remains and the pain goes on. The next doctor identifies the second ignores the first and the pain still continues. The child actually understands, if the right questions are asked, what is going on. A careful history can invariably uncover this issue as most children can distinguish the two problems. Recognizing this usually yields a good outcome. Ordering investigations is unfortunately a faster approach to acquiesce the child who has been having issues for a while and relieves the physician who is afraid of missing something serious.

If parents continue to have trouble utilizing the above approach, they could email their questions to  pediatricgi@downstate.edu