Patient information: Chronic abdominal pain in children and adolescents

ABDOMINAL PAIN OVERVIEW

Chronic and recurrent abdominal pain are common in children and adolescents. 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.

The pain is severe enough to limit a child's activity or school attendance over the course of at least three months. The terms chronic and recurrent may be used interchangeably.

A topic review that discusses abdominal pain in adults is available separately. (See "Patient information: Abdominal pain (functional dyspepsia) in adults".)

ABDOMINAL PAIN CAUSES

Overview — There are two major categories of chronic abdominal pain in children:

• Those that are clearly related to abnormalities in an organ system, such as the gastrointestinal, urinary, or gynecologic systems. These are called organic disorders.
• Those in which the cause is not identifiable or confirmed by tests are called functional disorders. However, not finding the cause does not mean that the child is not in pain.

In some cases these disorders are caused by disorganized movements of the intestine and/or a heightened sensitivity to abdominal pain. The pain may be triggered by anxiety or other emotional stress.

Organic and functional disorders are not mutually exclusive; psychological and organic conditions may exist together. Children with chronic pain often develop symptoms of depression and/or anxiety during the course of their illness. Conversely, children who are anxious or depressed may complain of pain (including abdominal pain or headaches).

Organic disorders — Organic disorders include conditions caused by an identifiable structural, infectious, or biochemical abnormality within the body. Constipation is one of the most common causes of recurrent pain. 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, endometriosis, inflammatory bowel diseases (eg, Crohn's disease, ulcerative colitis), and sexually transmitted infections.

Signs and symptoms — Features that suggest an organic disorder depend upon which disorder is present, but may include one or more of the following: (table 1)

• 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 cause a combination of signs and symptoms whose cause cannot be identified with laboratory tests (table 2). Examples include functional dyspepsia (stomach upset), irritable bowel syndrome (IBS), and abdominal migraine.

Functional dyspepsia — Dyspepsia is pain or discomfort that is centered in the upper abdomen. Discomfort may include feelings of stomach fullness, becoming full after eating a small amount of food, abdominal bloating, nausea, retching, or vomiting. It is sometimes difficult to differentiate functional dyspepsia from other gastrointestinal disorders; testing may be required.

Irritable bowel syndrome — Irritable bowel syndrome (IBS) has symptoms that include chronic abdominal pain and a change in bowel habits that has no known organic cause. IBS may be preceded by a long history of constipation or an episode of viral gastroenteritis. Symptoms of IBS are listed in the table (table 3). In one report, 45 percent of adolescents with chronic abdominal pain were classified as having IBS [1]. (See "Patient information: Irritable bowel syndrome".)

Abdominal migraine — Abdominal migraines are characterized by episodes of intense abdominal pain, centered in the mid-abdomen, lasting one hour or more. The pain is accompanied by other symptoms such as nausea, headache, or photophobia (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, and are thus described as having functional abdominal pain. The symptoms may be so severe that the child is frequently absent from school or unable to participate in activities.

The pain may be difficult to describe and locate. It is usually unrelated to meals, activity, or bowel movements, and may occur with other symptoms, such as nausea, dizziness, headache, and fatigue. Pain typically lasts less than one hour, and most children do not have difficulties with growth and development or other physical symptoms such as weight loss, fever, rash, joint pain or swelling. Many children with functional abdominal pain have a family history of gastrointestinal problems.

Functional abdominal pain may be caused by an extreme sensitivity to pain or a failure of the stomach to relax during eating. Most commonly, it is triggered by stress or anxiety. This may be seen during periods of change or stress in families (eg, the birth of a new sibling, illness of a family member), 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.

The parents' response to their child's pain can provide positive reinforcement for the child's behavior. The parents' response to their child's pain can provide positive reinforcement for the child's behavior. For example, if a child is seeking attention, any attention that the parent gives that is focused on the abdominal pain will tend to reinforce the symptom. And conversely, attention focused on the child's other activities may fulfill their need for attention and reduce the abdominal pain. Similarly, if a parent expresses worry about the causes of the pain, the child may become more anxious, and the pain may increase. (See 'Positive attention' below.)

ABDOMINAL PAIN DIAGNOSIS

History and physical examination — To determine the cause(s) of abdominal pain, a healthcare provider will ask about the child's and family's history of pain and psychosocial stressors. This can provide important clues about the cause of pain. Parents may wish to plan for these questions by reviewing the table (table 4).

Older children and adolescents should be allowed to give their own description of their pain, although younger children may need assistance from a parent. In addition, adolescents should be allowed to answer questions without the parent present; discussions about sexual activity, fears, and problems with a parent can be embarrassing or difficult to discuss when a parent is present. (See "Patient information: Depression in adolescents".)

The physical examination also is important in evaluating abdominal pain. The child's weight, height, and percentile on the growth chart help a clinician to determine if the child's growth and development are within the normal range. Children who are underweight or short or have fallen below their usual growth curve are more likely to have an organic disorder as a cause for their abdominal pain. (See "Patient information: Poor weight gain in infants and children".)

The clinician will examine the child's abdomen to determine if there is excess fluid or gas, enlargement of the abdominal organs, an abnormal mass, or pain with light and deep pressure. A visual examination of the anus and a digital (finger) exam of the rectum are important to determine if there is constipation or blood in the stool. A pelvic examination may be necessary for girls with a possible gynecologic problem.

Laboratory tests — Blood testing is sometimes recommended if the clinician suspects anemia, infection, or inflammation. Imaging tests such as x-ray are not usually required unless the child's history of physical examination indicates that an organic disorder may be present.

Pain diary — A pain diary is a record of pain felt by the child during his or her usual daily activities. Typically, it is recorded over the course of one week. It is useful in documenting patterns and other significant factors of the child's pain. At the end of each day, the child or family member records information about the day's pain (algorithm 1), including:

• An indication of severity (using a 1-5 or faces pain rating scale) (figure 1)
• The time of day pain occurred
• Whether the pain prevented activities (school, sports, play)
• Pain location
• Possible triggers (food, activities, stressors, thoughts, feelings)
• Duration of pain
• Remedies tried, and if pain improved with the remedy

The pain diary can be reviewed with the healthcare provider at the next office visit. Pain that occurs only during school hours or only at home suggests a functional disorder.

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.

As noted above, chronic abdominal pain in children is most often caused by a functional disorder for which a variety of treatments can be helpful, but no single treatment is best. Thus, most healthcare providers recommend trying several treatments. This may require several visits with a healthcare provider, especially when the pain has been present for a long period of time.

It is important for parents to build an ongoing relationship with the child's healthcare provider. This will enable the provider to continue his/her evaluation and try various treatment approaches. It is also important for parents to remember that a functional disorder does not imply that their child is not in pain or that it's "all in their head".

The primary goal of treatment is to help the child return to normal activities. A secondary goal is to improve the child's pain. However, it may take some time to determine the causes of the pain, and to find the most effective solutions. Thus, another important aspect of treatment is for the provider to help the child and family to cope with episodes of pain.

Although functional abdominal pain can be triggered or reinforced by a desire for attention, it is rare for a child to "fake" pain. It is important for parents to acknowledge that the child's pain is real and offer sympathy, support, and reassurance, while also taking steps 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 treatments that include relaxation and behavioral therapies to address these aspects of their pain.

Positive attention — During periods of change or stress in families, parents may have limited time to spend with their child. In some cases, a child can develop chronic or recurrent abdominal pain related to his or her need for attention. It may be helpful for a parent 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 also may be used during times of pain (table 5). A family member can act as "coach" if necessary (provided this attention does not provide positive reinforcement for the pain, as described above). The goal is to use a non-drug therapy to help the child relax when in pain.

Behavioral therapies — Behavioral therapies may be recommended for children or adolescents with functional abdominal pain. Cognitive-behavioral therapy, hypnosis, biofeedback, and psychotherapy help to reduce a patient's anxiety levels, encourage participation in normal activities, increase involvement in treatment, and improve tolerance of pain. A therapist or counselor in behavioral therapies can provide understanding and encouragement without allowing the child to withdraw from important activities such as school. This type of treatment is most likely to be successful in patients who have symptoms of pain that are associated with stressors, but may be tried by all patients with chronic pain.

Some patients and families are resistant to the idea of behavioral therapies. However, referral to a therapist does not imply 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 — Although there is little evidence supporting the effectiveness of dietary changes for children with chronic abdominal pain, the following treatments may be helpful in selected children.

Lactose — Lactose is a type of sugar found in milk and milk products (table 6). 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 may be helpful for children with these symptoms; this is done by eliminating milk and milk products or by using lactase enzyme replacements (eg, Lactaid® milk or Lactaid® drops). If symptoms of abdominal pain do not resolve after two weeks, milk and milk products may be restarted. There also are specific tests for lactose intolerance (a lactose breath test), which can be used if the diagnosis remains uncertain.

Fiber — A trial of a high-fiber diet may improve symptoms in some children who have constipation, or who have constipation as a component of irritable bowel syndrome (IBS). In children who are afraid of moving their bowels (stool withholding), it may be important to clean out the stool before adding fiber to the diet. (See "Patient information: Constipation in infants and children".)

For children, the minimum daily fiber intake (in grams) should equal the child's age (in years) plus five grams. For adolescents, 20 to 35 grams of fiber per day are recommended. By reading the product information panel on a food's package, parents can determine the fiber content of a particular food (figure 2).

High-fiber foods include fruit juices (prune, apple, or pear), high-fiber cereals, raw vegetables, salads, and bran-containing breads (table 7A-C). High-fiber cookies, granola bars, crackers, homemade trail mix (raisin bran cereal, dried fruits, and nuts), and fruit salad may be more acceptable to children and adolescents.

Children who do not like high-fiber foods may take an over-the-counter fiber supplement one to three times daily (table 8), which can be mixed with a flavored milkshake or other favorite beverage. Increasing dietary fiber can cause abdominal bloating or gas; starting with a small amount and slowly increasing the dose and frequency may minimize these side effects. (See "Patient information: High fiber diet".)

Other changes — Avoidance of foods, beverages, and medications that aggravate symptoms may be helpful in some children. Common triggers for functional dyspepsia include high-fat foods and caffeinated beverages. Foods that increase gas production (eg, beans, onions, celery, carrots, raisins, bananas, apricots, prunes, Brussels sprouts, cabbage, cauliflower, broccoli, asparagus, wheat germ) are not recommended for children who complain of gas. (See "Patient information: Gas and bloating".)

Medications that can cause gastrointestinal symptoms include nonsteroidal antiinflammatory drugs, such as aspirin and ibuprofen (Advil®, Motrin®).

Medications — Medications may be appropriate for some specific causes of abdominal pain. However, their role in functional abdominal pain in children is unclear. It is best to consult with a healthcare provider before trying medications.

ABDOMINAL PAIN FOLLOW-UP

A follow-up visit with the healthcare provider is usually scheduled two to four weeks after the initial visit to review test results, the child's response to dietary changes and/or medications, and the pain diary.

In some cases, the primary care provider will recommend referring the child to a specialist for further testing or evaluation. Specialists may include a behaviorist, adolescent medicine specialist, gynecologist, gastroenterologist, or therapist, depending upon the child's signs, symptoms, and responses to initial treatments. However, referral to a specialist is not needed for most children. Pain resolves in 30 to 70 percent of children by two to eight weeks after diagnosis, and children with functional causes of pain rarely develop more serious pain-related conditions.

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 greater than 102ºF (39ºC), or fever greater than 101ºF (38.4ºC) for more than three days. Table 9 describes how to take a child's temperature (table 9).
• 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

SUMMARY

• Chronic and recurrent abdominal pain are common in children and adolescents. The pain must be severe enough that the child is unable to do normal daily activities (eg, play, attend school).
• There are two categories of chronic abdominal pain: organic and functional disorders.

• - Organic pain disorders are caused by a problem or abnormality in the body. Causes of organic disorders include constipation, pain in the muscles or bones, pain from menstrual periods, and stomach problems (eg, reflux, ulcers) (table 1).
• - The cause of functional disorders cannot be determined with testing (table 2). A functional disorder does not mean that a child is not in pain or that it's "all in their head".

• Most children with chronic abdominal pain do not need to have tests (eg, x-rays, blood tests).
• There is no single treatment that is best for abdominal pain. Most doctors and nurses recommend trying several treatments (see 'Abdominal pain treatment' above. The goal of treatment is to help the child return to normal activities. A secondary goal is to improve the child's pain.
• Most children with chronic abdominal pain do not need to see a specialist. Pain disappears in 30 to 70 percent of children by two to six weeks after diagnosis. Children with functional pain rarely develop more serious conditions (see 'Abdominal pain follow-up' above.
• Children with chronic or recurrent abdominal pain who also have the following signs or symptoms need immediate medical care: bloody stools; severe diarrhea or vomiting; severe abdominal pain that lasts more than one hour, or severe pain that comes and goes and lasts more than 24 hours; refusal to eat or drink anything for more than a few hours; fever greater than 102ºF (39ºC), or fever over 101ºF (38.4ºC) for more than three days; and behavior changes, including lethargy or decreased responsiveness (see 'When to seek help for abdominal pain' above.

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. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your child's situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: Abdominal pain (functional dyspepsia) in adults
Patient information: Irritable bowel syndrome
Patient information: Headache in children
Patient information: Depression in adolescents
Patient information: Poor weight gain in infants and children
Patient information: Constipation in infants and children
Patient information: High fiber diet
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

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• 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/)

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