Patient education: Chronic abdominal pain in children and adolescents (Beyond the Basics)

CHRONIC RECURRENT ABDOMINAL PAIN OVERVIEW — Chronic and recurrent abdominal pain is common in children. The term "functional abdominal pain disorder" refers to pain that cannot be attributed to another medical condition after an appropriate medical evaluation has been conducted. Functional abdominal pain disorders (FAPDs) are considered the result of abnormal interactions between the gut and the brain. FAPDs are the most common cause of chronic abdominal pain in children and adolescents, occurring in 9 to 15 percent of all children. In males, pain is most common between ages 5 and 6 years. Females have pain most commonly between 5 and 6 years and 9 and 10 years.

In most cases, abdominal pain is not serious and gets better without treatment. However, when it is lasts a long time or happens over and over again and a specific cause has not been found, treatment can be difficult. The pain can affect the child's ability to have a normal life, including attending school. This topic reviews treatment approaches that can help your child cope with the pain and/or help the pain go away.

A topic review that discusses abdominal pain in adults is available separately. (See "Patient education: Upset stomach (functional dyspepsia) in adults (Beyond the Basics)".)

CHRONIC RECURRENT ABDOMINAL PAIN CAUSES

Organic disorders — Organic disorders include problems that have a specific cause. Organic disorders generally cause pain much less often than functional disorders.

Organic causes of abdominal pain include stomach and intestinal problems (eg, heartburn, ulcers, lactose intolerance, parasitic infections, inflammation of the esophagus) and abdominal muscle pain. Less common causes include urinary tract infection and inflammatory bowel diseases (eg, Crohn disease, ulcerative colitis). For females, problems with the uterus and ovaries, including infections, can also cause pain. Based on the symptoms, the doctor may perform appropriate tests to make sure your child does not have an organic cause for pain.

Features that suggest an organic disorder depend upon which disorder is present but may include one or more of the following warning signs:

●Pain that awakens the child or adolescent

●Significant vomiting, constipation, diarrhea, bloating, or gas

●Blood in the vomit or stool

●Unintentional weight loss or slowed growth

●Changes in bowel or bladder function

●Pain or bleeding with urination

●Abdominal tenderness (pain when the abdomen is pressed)

●Unexplained fever

Functional abdominal pain disorders — Functional abdominal pain disorders are characterized by symptoms that cannot be attributed to another condition after an appropriate medical evaluation. Examples include:

●Functional dyspepsia (stomach upset or bloating)

●Irritable bowel syndrome (IBS; due to intestinal cramping)

●Abdominal migraine ("migraine" of stomach)

●Functional abdominal pain (remainder)

The symptoms can be so severe that the child may have frequent absences from school and be unable to participate in activities.

Functional dyspepsia — Dyspepsia is pain or discomfort in the upper belly. Discomfort may be one of two types:

●General feelings of pain or burning not associated with bowel movements

●Stomach fullness or bloating after eating, even after eating small amounts of food

Irritable bowel syndrome — IBS causes symptoms including chronic abdominal pain and a change in bowel habits (diarrhea or constipation or both). (See "Patient education: Irritable bowel syndrome (Beyond the Basics)".)

Abdominal migraine — Abdominal migraines cause similar episodes of intense abdominal pain, centered in the mid-abdomen, lasting one hour or more. Between episodes the child is completely well for weeks to months. The child might also have loss of appetite, nausea, vomiting, headache, or sensitivity to light. Many, but not all, children with abdominal migraine have a family history of migraine. (See "Patient education: Headache in children (Beyond the Basics)".)

Functional abdominal pain — For children who have abdominal pain without a known cause and do not have specific symptoms of the other functional pain syndromes described above (functional dyspepsia, IBS, or abdominal migraine), the general term "functional abdominal pain" is used.

●The pain may be difficult to describe and locate

●It is usually unrelated to meals, activity, or bowel movements

●The pain may occur with other symptoms, such as nausea, dizziness, headache, and fatigue

●Pain typically lasts less than one hour

●Most children do not have problems with growth, weight loss, fever, rash, joint pain, or swelling

●Many children with functional abdominal pain have a family history of digestive problems

Functional abdominal pain is often triggered by stress or anxiety. This can happen during periods of change or stress in families (such as the birth of a new sibling, family member's illness), when the caregiver(s) has limited time to spend with their child. Starting school may also trigger recurrent abdominal pain. In some cases, children can develop chronic abdominal pain related to their need for attention.

Functional abdominal pain does not mean that the child does not have pain or that it is "all in their head." The pain may be due to regulatory factors in the nervous system of the gastrointestinal tract and brain, such as an increased sensitivity to pain, a decreased threshold for pain, abnormal pain referred after rectal distension, or impaired gastric relaxation to meals. Unfortunately, specific laboratory or imaging tests are not available to identify these regulatory factors. How caregivers respond to the child's pain can support continuation of pain. For example, if caregivers show that they are constantly worried about the child's pain, instead of relieving the child's pain, the child may become more anxious, and the pain may worsen. If instead the caregiver pays attention to the child's normal activities, the child's need for attention may be satisfied and their abdominal pain reduced. (See 'Positive attention' below.)

Chronic pain, regardless of source or etiology, can be associated with anxiety and depression, both as a cause and an effect.

CHRONIC RECURRENT ABDOMINAL PAIN DIAGNOSIS

History and examination — To determine the cause(s) of abdominal pain, the child's doctor or nurse will ask questions about the child's medical history (table 1). The doctor or nurse will also perform an examination. Blood tests and imaging studies are sometimes needed if there are signs of an organic disorder.

Pain diary — A pain diary is a way to keep track of a child's pain during usual daily activities. Typically, pain is recorded over the course of one week (including a weekend). At the end of each day, the following information is recorded (figure 1):

●How bad the pain was (for example, on a scale from 1 to 5)

●When the pain occurred

●If the pain prevented activities (school, sports, play)

●Where the pain was located

●Possible triggers (food, activities, stressors, thoughts, feelings)

●How long the pain lasted

●If anything helped the pain go away

You can review the pain diary with the doctor or nurse at the next office visit. Pain that tends to occur only during school hours or only at home suggests a functional disorder. However, some children with chronic abdominal pain have pain during fun activities as well.

CHRONIC RECURRENT ABDOMINAL PAIN TREATMENT — The child's doctor or nurse will review the information from the child's medical history, examination, and pain diary to look for clues to an organic disorder and pain triggers. If the child's doctor or nurse thinks that the child may have an organic disorder, the doctor or nurse may recommend additional testing and/or treatment.

However, chronic abdominal pain in children is most often caused by a functional pain disorder. There are a variety of treatments that can be helpful, but no single treatment is best. Most experts recommend trying several treatments. This may require several visits with the doctor or nurse, especially if pain has been a problem for a long time.

The first goal of treatment is to help the child return to normal function and activities such as school and playing with friends. A second goal is to improve the child's pain. However, it may take some time to figure out what is causing the pain and find the best treatment. It is also important for the child's doctor or nurse to help the child cope with pain. Finally, a functional pain disorder does not mean that the child does not have pain or that it's "all in their head."

It is important for parents and caregivers to build a good relationship with the child's doctor or nurse. This will allow the doctor or nurse to explore what might be making a child feel stressed, try various treatments, and continue their evaluation when necessary.

Although functional abdominal pain can be brought on by a desire for attention, it is rare for a child to "fake" pain. It is important to take complaints and concerns seriously, acknowledge that the child's pain is real, and offer sympathy and support, as well as reassurance that the pain is not life threatening. But also take care 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 inability to get relief. Co-occurrence of anxiety disorders and abdominal pain is common in children and adolescents. These conditions may share causative factors as a consequence of coping with chronic pain. Many children benefit from relaxation and behavioral therapies to help them cope.

Behavioral approach

Positive attention — During periods of change or stress in families, it can be hard for caregivers to spend enough time with their child. In some cases, the child will develop chronic or recurrent abdominal pain related to their need for attention. It may be helpful 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, which rewards negative behavior (complaining of pain).

Improved coping — Coping involves voluntary efforts to regulate emotions, thought, behavior, physiology, and the environment in response to stressful events or circumstances. Incorporating psychosocial treatments to improve coping is recommended because learning to cope with pain facilitates return to normal function.

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 can also be used during times of pain (table 2). A family member can act as "coach" if necessary (provided this attention does not provide positive reinforcement for the pain, as described above).

Distraction — Distraction techniques such as conversation, games, or television shift attention away from the pain.

Guided imagery/hypnotherapy — Clinical or gut-directed hypnosis with a trained therapist involves guiding a patient into a focused state of awareness and deep relaxation. The technique uses suggestion, imagery, and relaxation to calm the digestive tract and prevents unnecessary focus on discomfort in the body. Gut-directed hypnotherapy has been shown to have long-lasting benefits on reducing pain frequency and intensity.

Behavioral therapies — Behavioral therapies may be recommended for children or adolescents with functional abdominal pain that keeps the child from going about daily activities. Behavioral therapies may help to reduce the child's anxiety, help them to participate in normal activities, be involved in their treatment, or better tolerate the pain. Some common types of behavioral therapies are cognitive-behavioral therapy, biofeedback, and yoga.

A therapist or counselor can listen to the child and provide encouragement. Talking with a therapist may prevent the child from withdrawing from important activities such as school. This type of treatment is most likely to be successful in children who have pain related to stress, but it is a good option for anyone with chronic pain.

Older children and families are often resistant to the idea of behavioral therapies. However, seeing a therapist does not mean 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).

Return to school — School absence is common among children with chronic abdominal pain. School absences add to family stress and can interfere with the child's school performance and social functioning.

Return to school is an important part of helping a child with functional pain get better. The goal of treatment is return to normal activities rather than removal of pain. Caregivers can work with their child's doctor or nurse to develop a plan for returning to school. The plan may involve being allowed to go to the nurse's office for short periods of time until the pain subsides but limiting the number of visits each week. The child's doctor or nurse can help the caregiver understand when the child is too sick to go to school and provide guidelines for activity restrictions when the child stays home (eg, bedrest without television or other entertainment).

Management of triggers — Triggers may be identified by asking about aggravating and relieving factors or by asking the patient to keep a pain diary (figure 1).

Dietary triggers — We do not routinely restrict the diet of children with recurrent abdominal pain because the restriction can lead to nutrient deficiencies. By definition, these children do not have food allergies. However, on a case-by-case basis, restricting suspected dietary triggers for two weeks may be warranted. If no beneficial effect is seen with dietary restriction of suspected triggers after two weeks, a regular diet should be resumed.

Lactose — Lactose is a type of sugar found in milk and milk products (table 3). Children who are lactose intolerant often have symptoms of cramping pain, bloating, gas, or diarrhea related to eating or drinking lactose-containing products.

A lactose-free diet can help to ease these symptoms; this is done by eliminating milk and milk products or by using lactase enzyme replacements (eg, Lactaid milk or Lactaid drops). If abdominal pain does not get better after two weeks, the child can restart milk and milk product. There also are tests for lactose intolerance, which can be used if the diagnosis remains uncertain.

Fermentable sugars and FODMAPs — Carbohydrate malabsorption from fermentable sugars such as FODMAPs can lead to abdominal pain and bloating. FODMAP stands for fermentable oligosaccharides, disaccharides, monosaccharides, and polyols, which are short-chain carbohydrates (sugars) that the small intestine absorbs poorly. Poor absorption of these sugars may lead to gas production, bloating, distension of the large intestine, and abdominal pain. Food products high in FODMAPs may trigger irritable bowel syndrome (IBS). Examples include corn syrup, certain fruits (eg, apples, grapes, watermelon) and vegetables (eg, peas, asparagus, zucchini), and natural sweeteners (eg, honey, agave, maple syrup, molasses).

Information on the role of FODMAPs in functional abdominal pain disorders in children is limited. In some studies, a low-FODMAP diet has been associated with some improvement in gastrointestinal symptoms (eg, bloating, nausea). The low-FODMAP diet is complex and implemented in three phases. It should be managed by a dietician.

Gluten-free diets — Gluten-free diets are not recommended for children and adolescents with functional abdominal pain.

Other changes — In some children, there are foods, drinks, and medicines that make symptoms worse. Common triggers include:

●High-fat foods

●Caffeine

●Foods that increase gas (beans, onions, celery, carrots, raisins, bananas, apricots, prunes, Brussels sprouts, cabbage, cauliflower, broccoli, asparagus, wheat germ) (see "Patient education: Gas and bloating (Beyond the Basics)")

Medicines that can cause upset stomach include nonprescription pain medicines, such as aspirin and ibuprofen (sample brand names: Advil, Motrin).

Management of pain — Short-term trials of the following products are reasonable. Although their benefit is not well established, they have low risk of harm.

Probiotics — Probiotics are what many people call "friendly bacteria" or "good bacteria." They are bacteria that live in the body and help it work well. Often, probiotics help defend the body from infections caused by unfriendly bacteria or other germs. Probiotics get into the body on their own, so people can benefit from probiotics without doing or taking anything extra. But some people take pills that contain probiotics because they think the pills will help keep them healthy.

Probiotics are unlikely to be harmful and may be helpful for some children with chronic abdominal pain. However, the most effective strain, dose, and treatment duration are uncertain. Talk with your child's doctor or nurse before trying probiotics.

Fiber — Eating a high-fiber diet (increased fruits and vegetables or foods with added fiber) or supplementation with water-soluble fiber (eg, psyllium) for four weeks might improve symptoms in children who have constipation or constipation-predominant IBS by altering the composition of stool or improving transit through the gastrointestinal tract. In children who are afraid of moving their bowels (stool withholding), a "clean out" treatment is often recommended before adding fiber to the diet. (See "Patient education: Constipation in infants and children (Beyond the Basics)".)

Peppermint oil/antispasmodics — Peppermint oil (available commercially) is thought to decrease muscle spasms in the gastrointestinal tract and may be helpful in combination with general management strategies for IBS. However, it has not been shown to be effective in alleviating functional abdominal pain.

Auricular neurostimulation therapy — Auricular stimulation is a treatment given through a device that is worn behind the ear and sends electrical impulses into nerve bundles in the ear. This stimulation is thought to target areas in the brain involved in processing pain. Preliminary studies suggest that this treatment is safe and may be helpful for some children.

Medicines — Medicines might be needed for some specific causes of abdominal pain. Talk to your child's doctor or nurse before trying medicines.

WHEN TO SEEK HELP FOR ABDOMINAL PAIN — Parents and caregivers of children with chronic or recurrent abdominal pain who also have the following signs or symptoms should call their health care provider immediately:

●Bloody stools, severe diarrhea, or recurrent or bloody 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 higher than 102.2ºF (39ºC), or fever higher than 101ºF (38.4ºC) for more than three days. The table describes how to take a child's temperature (table 4).

●Pain when urinating, needing to urinate frequently or urgently.

●Behavior changes, including lethargy or decreased responsiveness.

Parents and caregivers should call their health care 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

WHERE TO GET MORE INFORMATION — Your child's health care provider is the best source of information for questions and concerns related to your child's medical problem.

This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients and caregivers, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Stomach ache and stomach upset (The Basics)
Patient education: Crohn disease in children (The Basics)
Patient education: Ulcerative colitis in children (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Upset stomach (functional dyspepsia) in adults (Beyond the Basics)
Patient education: Constipation in infants and children (Beyond the Basics)
Patient education: Irritable bowel syndrome (Beyond the Basics)
Patient education: Headache in children (Beyond the Basics)
Patient education: Gas and bloating (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Emergency evaluation of the child with acute abdominal pain
Chronic abdominal pain in children and adolescents: Approach to the evaluation
Functional abdominal pain in children and adolescents: Management in primary care

The following organizations also provide reliable health information.

●National Library of Medicine

     (www.nlm.nih.gov/medlineplus/healthtopics.html)

●The University of Michigan Child Development and Behavior Resources

     (https://www.uofmhealth.org/health-library/sig244830)

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