Recurrent Abdominal Pain in Children

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PatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

See also: Abdominal Pain written for patients

See also the separate article on Abdominal Pain in Children.

Recurrent abdominal pain (RAP) in children was defined and identified because it was recognised that it was very common, very disruptive to families and often not accompanied by easily definable organic pathology. It is a condition comprising both organic and functional disorders and is therefore clinically challenging to diagnose and treat.

Recurrent abdominal pain in children is of significance because:

  • It is one of the most common symptoms in childhood worldwide.
  • It is responsible for considerable morbidity, missed school days and high use of health resources.
  • It is made up of functional disorders (those which cannot be explained by structural or biochemical disorders) and organic disorders. Apley recorded that only 8% of patients with RAP had, after extensive investigation, any organic pathology.[1]
  • Diagnostic uncertainty, chronicity and increasing parental anxiety often follow the unremitting and disruptive course of the condition. This can make management by GPs and paediatricians very difficult, time-consuming and expensive.

Many recent studies now identify a significant proportion of patients with RAP as either clearly having irritable bowel syndrome (IBS) or going on to develop IBS.[1] Recurrent pain at other sites is common as well; however, the abdomen is the most common site for recurrent pain. There is considerable overlap between recurrent headache and recurrent abdominal pain.[2]

Recurrent abdominal pain

  • Abdominal pain that waxes and wanes, occurs for at least three episodes within three months, and is severe enough to affect a child's activities.

Chronic abdominal pain

  • Long-standing intermittent or constant abdominal pain.
  • Functional in most children (no objective evidence of an underlying organic disorder).

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Rome III criteria, 2006[4] 

Functional dyspepsia
No evidence of an inflammatory, anatomical, metabolic, or neoplastic process that explains symptoms. Criteria fulfilled at least once a week for at least two months - must include all of the following:

  • Persistent or recurrent pain or discomfort centred in the upper abdomen (above the umbilicus).
  • Not relieved by defecation or associated with the onset of a change in stool frequency or stool form.

IBS
No evidence of an inflammatory, anatomical, metabolic, or neoplastic process that explains symptoms. Criteria fulfilled at least once a week for at least two months - must include all of the following:

  • Abdominal discomfort (an uncomfortable sensation not described as pain) or pain associated with two or more of the following at least 25% of the time:
    • Improved with defecation.
    • Onset associated with a change in frequency of stool.
    • Onset associated with a change in form (appearance) of stool.

Functional abdominal pain
No evidence of an inflammatory, anatomical, metabolic, or neoplastic process that explains symptoms. Criteria fulfilled at least once a week for at least two months - must include all of the following:

  • Episodic or continuous abdominal pain.
  • Insufficient criteria for other functional gastrointestinal disorders.

Functional abdominal pain syndrome
Must include functional abdominal pain at least 25% of the time. No evidence of an inflammatory, anatomical, metabolic, or neoplastic process that explains symptoms. Criteria fulfilled at least once a week for at least two months - must include one or more of the following:

  • Some loss of daily functioning.
  • Additional somatic symptoms such as headache, limb pain, or difficulty in sleeping.

Abdominal migraine
No evidence of an inflammatory, anatomical, metabolic, or neoplastic process that explains symptoms. Criteria fulfilled two or more times in the preceding 12 months. Must include all of the following:

  • Paroxysmal episodes of intense, acute periumbilical pain lasting for one or more hours.
  • Intervening periods of usual health lasting weeks to months.
  • The pain interferes with normal activities.
  • The pain is associated with two or more of the following: anorexia, nausea, vomiting, headache, photophobia, pallor.
  • RAP is a common symptom in children. It occurs in as many as 10% of children.
  • An organic cause is found in few of these patients. However, differences in prevalence of organic disease are found depending on the population studied and the criteria used. It may be as low as 5% in the general population and as high as 40% in paediatric gastroenterology outpatients.
  • It is still the case that the paucity of organic pathology in these patients has led to the conclusion that psychological factors are important. However, this is not always reflected in the results of studies which do not always demonstrate differences in emotional and behavioural scores in the patients with organic pathology and in those without.[5]
  • It occurs most commonly between ages 4 and 14 years. Some studies show within this age range peaks in incidence at 4-6 years and at 7-12 years.[3]
  • Girls are probably affected more often than boys.
  • Incidence appears similar in different socio-economic groups, although low socio-economic status is cited by some as a factor increasing incidence.[3]
  • Recently, an association between obesity and RAP has been reported.[6] Diet may also play a part. A recent study reported an inverse correlation between fruit consumption and RAP.[6] It is apparent that many factors are involved, consistent with the concept of a biopsychosocial model for illness.[3][7]
  • Sexual abuse. Little is known about the association with sexual abuse, but studies do confirm that the duration of symptoms is longer in children who were victims of sexual abuse.[3]
  • Parental anxiety in the first year of life is associated with chronic abdominal pain before the age of 6 years. This may be because the anxiety prompts a response which strengthens recurrence of pain.[3]
  • Family factors are important and children with a parent with gastrointestinal problems are more likely to have RAP.
  • There may be a history of illness in siblings.[8]

From the published studies it seems that the causes of RAP are multifactorial. A bio-psychosocial model has been proposed which suggests a concept which acknowledges a complex interplay between many different factors. This is useful when considering management (ranging from behavioural treatments to pharmacological ones) and when explaining the condition to parents and children.

Alarm symptoms when a child presents with chronic abdominal pain[3]

  • Involuntary weight loss.
  • Deceleration of linear growth.
  • Gastrointestinal blood loss.
  • Significant vomiting.
  • Chronic severe diarrhoea.
  • Unexplained fever.
  • Persistent right upper or right lower quadrant pain.
  • Family history of inflammatory bowel disease.
Clinical features of organic and non-organic causes of recurrent abdominal pain
Clinical featuresOrganic causesNon-organic causes
Site of pain:Anywhere but particularly flanks and suprapubic pain. Note especially persistent right upper or right lower quadrant pain.Usually central and often epigastric.
Family history (particularly of abdominal pain, headache and depression):Less likely, but take note of a family history of inflammatory bowel disease.More likely.
Psychological factors (particularly anxiety):Less likely (but see text).Anxiety more likely.
Headache:Less likely.More likely.
Alarm symptoms (see above):

Alarm symptoms more likely:

  • Vomiting generally equally likely but beware persistent or significant vomiting.
  • Chronic severe diarrhoea more likely.
  • Unexplained fever.
  • Gastrointestinal blood loss.
Alarm symptoms less likely.
Abnormal signs:Present.Absent.
Abnormal growth and/or involuntary weight loss:Present.Absent.
Abnormal investigations:
FBC, ESR, urinalysis, for example.
Expected.Not found.

History

A good history is traditionally the cornerstone of diagnosis. It is not yet possible to define a questionnaire or diagnostic tool but the attempts are interesting and enlightening. Ultimately, they may yield a helpful diagnostic questionnaire but, at the moment, there is no substitute for a careful and thorough history.

  • The history should include an analysis of the pain:
    • Site of pain.
    • Quality and nature of pain.
    • Information on the timing and duration of pain.
    • Whether pain is relieved by defecation or not.
    • It is particularly important to ask about any associations with the pain and particularly the effect on daily living.[9]
  • The history should encompass enquiry about:
    • Gastrointestinal symptoms including bowel habit.
    • Genitourinary symptoms.
    • Past medical history. It is important to review any past illnesses, hospital admissions, relevant perinatal and neonatal history.

Examination

There are no good data evaluating the diagnostic value of physical examination.[3] However, careful and thorough examination is generally recommended, particularly when first seen. Typically, there may be vague tenderness but no guarding or rigidity. It can be reassuring to parents to see that this is done and to discuss findings, including the reassurance of normal findings. Examination should include at least the following:

Discriminating between organic and functional causes of RAP

The traditional view

  • Children presenting with RAP are unlikely to have organic disease.
  • Diagnostic triage is entirely appropriate in primary healthcare.
  • Diagnosis can be difficult. However, discriminating organic from functional disorders is achieved with a good history and without protracted examinations and investigations. Simple tests such as urine testing are usually all that is required.
  • The history helps to exclude organic causes and identifies important factors which may be triggering the pain.
  • The diagnostic process may be followed also in part to reassure parents.
  • It can be difficult to reassure parents when the pain continues and diagnostic uncertainty exists.

Recent perspectives[3]
Whilst there is acceptance of the traditional approach, it should be remembered that:

  • There is a long list of possible causes for recurrent abdominal pain. It is not possible categorically to exclude them all with definitive testing or investigation.
  • The distinction between so-called organic disease, functional disorders and emotional factors can be difficult. Frequently there is overlap between physical and emotional illness and the two may co-exist.
  • The history in children can be difficult. There may be difficulties describing the pain and localising it once the pain has passed. The child's vocabulary may limit description but there may also be emotional and psychological barriers to the process of history taking.

It is perhaps not surprising that a committee of American paediatric gastroenterologists recently concluded that there were no diagnostic tools to distinguish functional from organic abdominal pain.[3] They recommend further diagnostic testing only in children with alarm symptoms or signs, such as those outlined in the table above. They recommend abandoning the term 'recurrent abdominal pain'.

The list of possible causes is long but the list of probable causes is shorter.

Investigations may be required to exclude particular conditions suggested by the history and examination. It is useful to pursue further diagnostic testing only in the presence of alarm symptoms.[3] Such tests include comprehensive metabolic screening, stool analysis, inflammatory markers and other laboratory tests. These help to identify conditions such as inflammatory bowel disease and coeliac disease. Extensive investigations are not usually indicated or helpful. No studies have evaluated the usefulness of common laboratory tests.[3] These basic tests are often recommended:

  • FBC.
  • ESR or CRP.
  • Coeliac disease serology - IgA anti-tissue transglutaminase antibodies (tTGAs).
  • Urinalysis and microscopy.
  • Stool examination for parasites.
  • Plain abdominal X-ray.

Many tests may be done selectively, but it is worth considering that many tests when studied do not discriminate between functional and organic pain. As such they should not be used in an attempt to 'screen' for organic disease. Further tests which may be used include:

In fact, studies show positive results for each of these tests equally in control groups and in the patients with chronic abdominal pain.[3]

There has been shown to be an association between children with chronic abdominal pain and irritable bowel syndrome as adults (especially girls) and also a risk of later emotional symptoms and psychiatric disorders, particularly anxiety disorders.[3]

RAP will require follow-up and may need referral. It cannot be dealt with in a single consultation. Most children with RAP have mild symptoms which are successfully managed in primary care.[3] A detailed plan of management will depend on diagnosis. It is likely that a significant part of management will involve discussion, explanation and reassurance. A specific treatment or intervention cannot be recommended because none has yet been identified.[3] A summary of these is as follows:[3]

Beneficial treatments include:

  • There is some evidence that cognitive behavioural therapy (CBT) may be a useful intervention for children with recurrent abdominal pain although most children, particularly in primary care, will improve with reassurance and time.[13]
  • Family therapy - often part of the CBT approach and effective.
  • There is weak evidence for benefit of medication in children with recurrent abdominal pain. It is recommended that medication should be limited to those children with severe symptoms which have not responded to simple management. The following medications have been used:[14]
    • Peppermint oil for IBS.
    • Pizotifen for abdominal migraine.
    • H2-receptor antagonists for children with severe dyspeptic symptoms.
  • There is a lack of high-quality evidence on the effectiveness of dietary interventions. There is no evidence that fibre supplements, lactose-free diets or lactobacillus supplementation are effective in the management of children with recurrent abdominal pain.[15]
  • Many of the studies on prognosis relate to hospital practice not primary care.[3]
  • It is generally more likely that children with recurrent abdominal pain will develop chronic abdominal symptoms in adulthood and as many as 30% may continue thus.[3]
  • Many will continue to suffer from IBS.[1][5][16]
  • There is evidence that children with chronic abdominal pain are more likely to have emotional and psychiatric disorders later in life.[3]
  • Generally speaking, however, follow-up studies show that parental factors rather than the psychological characteristics of the child are more important when predicting persistence of abdominal pain.[3]
  • Possible risk factors for chronicity:
    • Age may be a factor although studies are inconclusive. Presentation under the age of 6 has been reported as a risk factor.
    • History of more than six months before presentation.
    • Family history of emotional factors. There is evidence that parental functional problems, stressful life events and sexual abuse are all associated with persistence of functional abdominal pain.
    • Anxiety, depression and severity of pain have not been linked to persistence of functional abdominal pain.
    • Eating and sleeping problems, phobias, nocturnal enuresis and other such factors have been cited. These may reflect emotional factors within the family.
  • Acceptance by parents of the role of psychological factors in the maintenance of symptoms is strongly associated with recovery.

Further reading & references

  1. El-Matary W, Spray C, Sandhu B; Irritable bowel syndrome: the commonest cause of recurrent abdominal pain in children. Eur J Pediatr. 2004 Oct;163(10):584-8.
  2. Galli F, D'Antuono G, Tarantino S, et al; Headache and recurrent abdominal pain: a controlled study by the means of the Child Behaviour Checklist (CBCL). Cephalalgia. 2007 Mar;27(3):211-9.
  3. Berger MY, Gieteling MJ, Benninga MA; Chronic abdominal pain in children. BMJ. 2007 May 12;334(7601):997-1002.
  4. Rome III Diagnostic Criteria for Functional Gastrointestinal Disorders
  5. Nygaard EA, Stordal K, Bentsen BS; Recurrent abdominal pain in children revisited: irritable bowel syndrome and psychosomatic aspects. A prospective study. Scand J Gastroenterol. 2004 Oct;39(10):938-40.
  6. Malaty HM, Abudayyeh S, Fraley K, et al; Recurrent abdominal pain in school children: effect of obesity and diet. Acta Paediatr. 2007 Apr;96(4):572-6.
  7. Stafford B, Troha C, Gueldner BA; Intermittent abdominal pain in a 6-year-old child: the psycho-social-cultural Curr Opin Pediatr. 2009 Jun 10.
  8. Guite JW, Lobato DJ, Shalon L, et al; Pain, disability, and symptoms among siblings of children with functional abdominal pain. J Dev Behav Pediatr. 2007 Feb;28(1):2-8.
  9. Roth-Isigkeit A, Thyen U, Stoven H, et al; Pain among children and adolescents: restrictions in daily living and triggering factors. Pediatrics. 2005 Feb;115(2):e152-62.
  10. Carson L, Lewis D, Tsou M, et al; Abdominal migraine: an under-diagnosed cause of recurrent abdominal pain in children. Headache. 2011 May;51(5):707-12. doi: 10.1111/j.1526-4610.2011.01855.x. Epub 2011 Mar 11.
  11. Cuvellier JC, Lepine A; Childhood periodic syndromes. Pediatr Neurol. 2010 Jan;42(1):1-11. doi: 10.1016/j.pediatrneurol.2009.07.001.
  12. Polito C, La Manna A, Signoriello G, et al; Recurrent Abdominal Pain in Childhood Urolithiasis. Pediatrics. 2009 Nov 9.
  13. Huertas-Ceballos A, Logan S, Bennett C, et al; Psychosocial interventions for recurrent abdominal pain (RAP) and irritable bowel syndrome (IBS) in childhood. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD003014. doi: 10.1002/14651858.CD003014.pub2.
  14. Huertas-Ceballos A, Logan S, Bennett C, et al; Pharmacological interventions for recurrent abdominal pain (RAP) and irritable bowel syndrome (IBS) in childhood. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD003017. doi: 10.1002/14651858.CD003017.pub2.
  15. Huertas-Ceballos AA, Logan S, Bennett C, et al; Dietary interventions for recurrent abdominal pain (RAP) and irritable bowel syndrome (IBS) in childhood. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD003019. doi: 10.1002/14651858.CD003019.pub3.
  16. Pace F, Zuin G, Di Giacomo S, et al; Family history of irritable bowel syndrome is the major determinant of persistent abdominal complaints in young adults with a history of pediatric recurrent abdominal pain. World J Gastroenterol. 2006 Jun 28;12(24):3874-7.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Richard Draper
Current Version:
Peer Reviewer:
Dr Hannah Gronow
Document ID:
2705 (v22)
Last Checked:
11/02/2013
Next Review:
10/02/2018

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