Abdominal Pain

How Do I Know if My Child's Pain Is Serious?

Most serious cause of abdominal pain have other symptoms in addition to the pain. Watch for these red flags and contact your primary care doctor if your child:

• Is losing weight or not growing normally

• Is vomiting

• Has bloody diarrhea, not just blood on the toilet tissue or outside of a stool

• Is less active between episodes of pain

• Has blood in the urine or pain when urinating

• Has fever, rash, chills, joint pain or swelling, or severe prolonged diarrhea

• Has a family history of inflammatory bowel disease or celiac disease

What Causes Abdominal Pain?

There are many causes of abdominal pain. Some common causes are functional abdominal pain, gastroesophageal reflux (heartburn), excess sugar intake, constipation, inflammation, kidney or liver or pancreas problems, and pain associated with anxiety.

Functional Abdominal Pain

Pain often results from cramping of the GI tract as it reacts to food or stress. Pain fibers may be more sensitive, so normal actions of the GI tract can be felt as pain. Hormones that the body produces during stress can also make pain sensations more severe. This is the most common type of pain in childhood. The child may also complain of nausea, bloating, and feeling full after eating small amounts.

Gastroesophageal Reflux (Heartburn)

Heartburn is a common cause of abdominal pain in children. Children rarely get ulcers, but they can get inflammation of the esophagus or stomach which is painful. This may be caused by acid or infections. The symptoms may include:

• Pain in the center abdomen just below the ribs or under the breast bone

• Nausea

• Vomiting

• Feeling full quickly

• Fullness or bloating

• Pain caused/helped by eating

• Heartburn

• Pain at night

• Pain relieved by antacids

• Bad Breath

Sugar Intake

Abdominal pain is often due to cramping from drinking too much juice or milk. Children don’t always fully absorb the sugars in juice, sports drinks, flavored drinks, gum, candy and milk. These sugars then go to the colon where the bacteria ferment the sugar and turn into gas. This can cause cramps. Because it may take a number of hours for this to happen, the pain is not felt at the time the child eats or drinks the sugary food. If the child drinks only water for a few days and eats no gum or candy, the pain will go away

Inflammation

An inflammation of the GI tract may also cause pain. Usually the child also has weight loss, tiredness and low blood counts.

Liver/Gallbladder, Pancreas, or Kidney Problems

Liver or gallbladder problems or an inflamed pancreas may also cause pain. Lab tests will help evaluate these. Kidney problems (blockages or other malformations) and infections may cause abdominal pain. Girls may also have abdominal pain when they are ovulating or having their periods. Cysts on an ovary may also cause pain.

Anxiety

Children may also have abdominal pain because of stress, depression, or general anxiety.

What Evaluations Can Be Done for Chronic Abdominal Pain?

First your child will have a complete medical history and physical exam. Then your child’s doctor or nurse practitioner will decide if further testing should be done. Most children will not need a lot more testing.

Some of the evaluation that may be done include:

• Growth Chart - Growth Problems are often a sign of other medical problems. Previous heights and weights are important in judging a child’s abdominal pain. It is very important that you make this information available to your child’s doctor or nurse practitioner

• Activity Level - It’s important for the doctor or nurse practitioner to know whether or not your child can carry on normal activity such as sports, school, and play between episodes of pain. Knowing this will help them determine what may be wrong.

Some of the tests that may be done include:

• Lab Tests

  • CBC- Blood counts, including hemoglobin and iron levels, can point to bleeding or inflammation that can prevent the absorption of iron.

  • Erythrocyte Sedimentation Rate (ESR) or C-reactive protein (CRP) - These tests look for inflammation anywhere in the body. They are not specific for the GI tract and can’t tell “where or why.”

  • Kidney and Urine Tests- Blood tests (BUN, Cr) and urine tests (urinalysis and calcium levels in urine) look for injury to the kidney, blood in the urine, and evidence of kidney stones.

  • Amylase, Lipase- Looks for inflammation of the pancreas.

  • Stool alpha-1-antitrypsin, albumin- Looks for protein loss because of an inflamed gastrointestinal tract.

  • Stool Guaiac- Looks for bleeding.

  • Stool O & P- Looks for parasites such as Giardia

  • C13 Breath Test- Looks for Helicobacter Infection (a cause of ulcer and inflammation in the stomach)

• Imaging Tests

  • Upper GI- Looks at the anatomy for things like improper attachment of the intestine to the back of the abdomen or areas of narrowing due to inflammation. This is not a good way to look for reflux or ulcer in children.

  • Ultrasound- An excellent way to look at the kidneys, ovaries, liver, gallbladder, and pancreas. This test will also check for masses in the abdomen.

  • CT Scan- Looks for masses and inflammation in the abdomen.

• Other Tests

  • Endoscopy/colonoscopy- This test uses a scope which is a long, flexible tube with a light and camera at the end to look at the esophagus, stomach, small intestine and colon. It can help to find inflammation and infection of the gastrointestinal tract.

What Treatment Will Be Tried?

It is fairly common for all the tests that look for causes of chronic abdominal pain to be normal. Your doctor or nurse practitioner may suggest some of these ways to help your child.

• Reassuring your child - Often we cannot make abdominal pain go away, and parents’ anxiety can only make the pain worse. Knowing that there is not a serious or life-threatening problem can be important in reducing the pain. Learning how to relax during pain can help children cope with their cramps. Your child may also benefit from a psychology visit to learn relaxation techniques, much like it is done to treat headaches, another common symptom that does not have a specific treatment.

• Diet Therapy - Fermentable sugars-the sugars in drinks and candy- are often poorly absorbed. They ferment in the intestine, causing gas and cramps. Your doctor or nurse practitioner may suggest that you try eliminating fructose and sorbitol for about a week. This means no gum, candy, juice, or sweet drinks other than milk and water. One week is usually long enough. Your doctor or nurse practitioner may also suggest a week-long trial of no dairy products to see whether your child can handle the sugar in milk. Caffeine or carbonated drinks may also bother your child.  Many children feel better with a higher fiber intake. Slowly increase the amount of fiber in your child’s diet. The number of grams of fiber needed daily is equal to your child’s age plus five.

• Medicines - Three different types of medicines may be used for treatment.

  • Anti-spasm medicines including Levsin, Levbid, and Bentyl

  • Acid reduction medicines such as Zantac, Tagamet, Pepcid, Axid, Prilosec, Prevacid, Nexium, Protonix, Aciphex.

  • Pain fiber modulation medicines that make the pain fibers less sensitive include Elavil, Periactin, Neurontin, and others.

When Should My Child Be Seen Again by the Doctor or Nurse Practitioner?

A child should be seen by the primary care provider if symptoms change, if there is weight loss, or there are other signs of serious illness. Watch for these warning signs (red flags) and contact your primary care doctor if your child:

• Is not growing normally

• Is vomiting

• Has bloody diarrhea, not just blood on the tissue or outside of a stool

• Is less active between episodes of pain

• Has blood in the urine or pain when urinating

• Has fever, rash, chills, joint pain or swelling, or severe prolonged diarrhea

• Has a family history of inflammatory bowel disease

What Should I Expect for My Child With Chronic Abdominal Pain?

Symptoms of chronic abdominal pain will come and go over time. Your child may have several good months followed by a time when there is more discomfort. Viral illnesses may make the pain fibers more sensitive, bringing on an increase in symptoms. Hormones produced by excitement or stress may cause pain fibers to sense more pain. These hormones are produced with events like birthdays, trips, sleepovers and school. Assuring your child that the tests did not find serious illness can often help the child ignore the symptoms. It may help to make sure your child know about all the things we know he or she doesn’t have.

Should I Send My Child to School When They Have Pain?

Children should attend school unless they have a fever or are vomiting. Long absences from school only increase anxiety about returning to school and can make the pain worse. Usually you can arrange with the school for your child to lie down for a short time during more severe pain. Most schools would rather make some changes so that the child doesn’t have to miss so much school.

How Can I Explain This to My Young Child?

The gastrointestinal tract is a lot like the long air balloon that clowns use to make animals. If you fill the balloon halfway with air, you can gently push the air back and forth, from one end to the other. That is how the gastrointestinal tract is supposed to mix food. If you squeeze two spots close together on the balloon, the balloon will stretch out between the squeezes. That can happen in the intestine causing cramps.  The intestine doesn’t like to be stretched and hurts. If you are upset or excited, the gut squeezes harder, and the middle stretches further and hurts more. We get rid of juice and candy to get rid of gas that can make the intestine stretch further. We try and get you to relax to make the cramping less. Your body may also be extra sensitive to squeezing. We may give you medicines to help you ignore some of that squeezing.