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

OVERVIEW — 

Chronic and recurrent abdominal pain is common in children. It refers to pain that is present for at least a few months ("chronic") or keeps coming back in a similar pattern ("recurrent").

In many cases, abdominal pain as well as other gastrointestinal (GI) symptoms are caused by disorders of gut-brain interaction (DGBIs). DGBI is a general term that describes a group of chronic conditions affecting the communication between the brain and the gut (where "gut" refers to the GI tract, including the stomach and intestines). This group of conditions was previously known as "functional gastrointestinal disorders."

These conditions are the most common cause of chronic abdominal pain in children and adolescents, occurring in approximately 10 percent of all children, and are particularly common in children between six years and mid-adolescence. Children with these conditions usually have normal test results (such as blood tests and X-rays) even when symptoms cause significant distress.

In most cases, this type of chronic abdominal pain is not serious and often improves without treatment. However, if it affects your child's ability to have a normal life, including attending school, there are ways that you can help your child cope with the pain and/or help the pain go away.

This article discusses the main causes and treatment of abdominal pain in children and adolescents. More detailed information about abdominal pain in children, written for health care providers, is available by subscription. (See 'Professional level information' below.)

CAUSES OF CHRONIC ABDOMINAL PAIN

Disorders of gut-brain interaction — Disorders of gut-brain interaction (DGBIs) are a group of disorders in which symptoms are caused when the gut and the brain are not communicating properly in either direction (from gut to brain and brain to gut), rather than a clear physical problem in the gut (like an ulcer or inflammation) (figure 1). The symptoms can be so severe that the child may have frequent absences from school and be unable to participate in activities. However, with therapies and support, the child can resume normal activities and symptoms usually improve over time and often go away completely at some point.

This type of abdominal pain is often triggered or made worse by stress or anxiety. This can happen during periods of change or stress in families, such as the birth of a new sibling, relocation, a family member's illness, mental health challenges, or a family conflict. It can also happen when the child returns to school or is feeling stressed at school. In some cases, the symptoms increase when the child feels a need for support or attention. Treatment can include strategies to recognize and address the social and emotional factors that contribute to pain. (See 'Talking to your child about the pain' below and 'Behavioral approaches' below.)

It's important to recognize that while things like stress and anxiety can play a role, this does not mean that the child does not have pain or that it is "all in their head." Instead, the pain may be related to the interaction between the gastrointestinal (GI) tract and brain. For example, some children might be more sensitive to pain. Sometimes, for example, nerves in the gut can send pain signals during normal digestion, such as when the stomach expands with a meal or when there is a muscle contraction in the rectum. In some cases, pain can continue for weeks or months after a child has recovered from an infection, such as a stomach virus or flu. Unfortunately, there are no tests to definitively confirm that the ongoing pain is related to gut-brain interactions.

DGBIs are divided into four categories, with different patterns of symptoms:

●Functional dyspepsia – Dyspepsia is pain or discomfort in the upper mid-belly. It can feel like:

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

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

The term "dyspepsia" usually means that the problem is caused by stomach acid (eg, gastroesophageal reflux disease). However, "functional" dyspepsia is not explained by stomach acid. The symptoms sometimes improve with medicines used to treat acid reflux but do not go away completely.

●Irritable bowel syndrome (IBS) – IBS causes a range of symptoms including chronic abdominal pain (often "crampy") and a change in bowel habits (diarrhea, constipation, or both). This category usually applies to older adolescents and adults rather than younger children. (See "Patient education: Irritable bowel syndrome (Beyond the Basics)".)

The symptoms associated with IBS can sometimes overlap with other types of DGBI or chronic constipation, so appropriate treatment depends on the main pattern of symptoms over time. (See "Patient education: Constipation in infants and children (Beyond the Basics)".)

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

●Functional abdominal pain – This category describes abdominal pain that has no known cause and does not fit into one of the other abdominal pain types described above (functional dyspepsia, IBS, or abdominal migraine). Common characteristics include:

•The pain may be difficult to describe and locate

•It is usually unrelated to meals, activity, menstruation, or bowel movements

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

•The episodes typically last less than one hour

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

•Many children have a family history of digestive problems or migraines

Other possible diagnoses — There are several other conditions that can cause abdominal pain as well. In the past, there was a major distinction between "organic" conditions (where there is a clear physical change or damage to the body that can be detected by diagnostic testing) and "functional" disorders (where a child experiences symptoms without any identifiable physical abnormality). Most chronic and recurrent abdominal pain in children is not caused by an "organic" disorder in the traditional sense, but experts now understand that making this distinction is not always possible, helpful, or necessary, and medical specialists are generally moving away from using these terms.

●Examples – Other conditions that can cause abdominal pain can involve different parts of the body. Examples include:

•Esophagus and stomach – Esophagitis (acid- or allergy-induced inflammation of the esophagus), gastritis, or ulcers

•Intestine – Celiac disease, inflammatory bowel disease (Crohn disease or ulcerative colitis), or infections

•Uterus and ovaries – Menstrual pain, infections, and other causes

•Muscles – Abdominal muscle strain

•Bladder and kidneys – Urinary tract infection

●Warning signs – Signs or symptoms that suggest a condition other than a DGBI include one or more of the following:

•Pain that awakens the child or adolescent from sleep

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

•Blood in the vomit or stool

•Bile in the vomit (causing it to be green or very bright yellow)

•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

EVALUATION — 

If your child's abdominal pain is interfering with their daily life or if you have other concerns, talk to their health care provider. They can do an evaluation to try to diagnose the cause of the symptoms, which usually includes a history and examination, as described below.

History and examination — To determine the cause(s) of abdominal pain, the health care provider will ask questions about your child's symptoms and medical history (table 1). They will also do a physical exam.

Pain diary — To understand the cause(s) of your child's abdominal pain, it might help to keep a pain diary to track the patterns during usual daily activities. For example, you can record any episodes of pain that happen for one typical week (including a weekend). At the end of each day, record the following information (form 1):

●When the pain happened

●How bad the pain was (for example, on a scale from 0 to 5)

●If the pain prevented your child from doing usual 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 health care provider at the next office visit. Pain that tends to occur mostly in one setting (such as mostly at school or mostly at home) suggests a disorder of gut-brain interaction (DGBI). However, some children have pain in multiple settings and during fun activities as well as stressful or boring activities.

Tests — The health care provider can usually diagnose the cause of the abdominal pain based on the symptom pattern and physical examination. Depending on the pattern of symptoms, they might also recommend specific tests. For example, they might recommend a blood test for celiac disease because it is a relatively common cause of chronic abdominal symptoms and poor growth. Or, if a child has bloody diarrhea, they might recommend testing for inflammatory bowel disease.

TREATMENT FOR DISORDERS OF GUT-BRAIN INTERACTION — 

After the child's health care provider has performed a thorough history and physical examination, including looking for any concerning signs or symptoms, they may be able to make a diagnosis of a disorder of gut-brain interaction (DGBI), often without additional diagnostic testing. For children with chronic abdominal pain caused by a DGBI, a variety of treatments can be helpful, but no single treatment is best for all situations.

The symptoms might start to improve with some relatively simple things that you can do at home. Or, you might need to try several approaches over months before you start to see improvement, especially if your child has had symptoms for a long time or if you or your child are facing other stresses. Most experts recommend trying several treatments. A health care provider or therapist can help you choose a treatment plan and readjust it as needed.

It is important to build a good working relationship with your child's health care provider. This will allow them to explore what might be making a child feel stressed, try various treatments, and continue their evaluation when necessary (such as if your child has new or worsening symptoms).

It is also essential for you to have open and supportive communication with your child to encourage them to express their feelings freely. This can help identify certain types of stress that could be contributing to their symptoms.

Talking to your child about the pain — Having a realistic and shared understanding of the pain is important for recovery. It is important to take your child's complaints and concerns seriously, acknowledge that their pain is real, and offer sympathy and support as well as reassurance that the pain does not mean that they have a serious illness or problem. The following messages can help your child understand their condition, reduce their anxiety, and be patient with the gradual recovery process:

●Goals – The first goal of treatment is to help your child return to normal function and activities such as school, extracurricular activities, playing with friends, and having fun. A second goal is to improve their pain. However, it may take some time to figure out what triggers the pain and find the best treatment.

●Cause of the pain – Start by acknowledging that the pain is real. Explain that stress or anxiety can worsen any type of pain, which is why relaxation exercises and normal activities often help. Explain that there are no signs that the pain is serious and that you and the health care provider will keep checking if needed.

●Therapy – If your child needs to see a counselor or therapist as part of treatment, explain that this can give them tools for coping with and reducing the pain, returning to normal activities (including school), and eventually recovering. A diagnosis of a DGBI does not mean that the child does not have pain or that it's "all in their head."

Return to school — School absence is common among children with chronic abdominal pain. Staying home might feel less stressful to your child initially. However, frequent or extended school absences can actually increase stress in the long run because it interferes with the child's learning and friendships and makes the return to school harder. Absences can also add to family stress.

If your child misses school a lot because of pain, returning to school is an important part of helping them get better. You can work with your child's health care provider, counselor, or therapist to develop a plan for returning to school. The plan might involve some temporary accommodations to help them function in school, such as 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 nurse or counselor can also help you create a plan for deciding when your child is too sick to go to school (such as if they have a fever or an infectious illness) and provide guidelines for activity restrictions when the child stays home (such as resting without television or other entertainment).

Behavioral approaches — A variety of approaches can help your child cope with and recover from their chronic abdominal pain.

●Caregiver-led – Many children have pain when they are feeling anxious or vulnerable. Here are some things that caregivers and family members can do to help:

•Validation – Listen actively, and acknowledge your child's pain without dismissing their concerns.

•Reassurance – Reassure your child that the pain is not dangerous and can be managed. If you show a lot of worry about your child's pain, your child will feel more anxious and this can make the pain worse.

•Encourage normal activities – Support your child in continuing with school, hobbies, and social interactions despite pain, as much as possible. Techniques such as conversation or games can help to shift their attention away from the pain.

•Positive attention and feedback – During periods of change or stress, children often seek extra attention or support. This is not the same as "faking" pain (which is uncommon in children). Try to find ways to give your child attention that are not related to their symptoms. For example, you might put aside some time every day to do an activity together or just to talk. Giving your child positive feedback for attending school or doing their regular activities can also help reinforce these behaviors and help them return to normal functioning.

•Acknowledge the pain, provide support, and reinforce "health" over "illness":

-Acknowledge the pain without giving it too much attention. For example, aim to have one specific time every day to briefly check in with your child about their symptoms. Avoid dismissing your child's pain completely or expecting them to ignore it completely.

-Try not to allow the pain to disrupt normal activities (for example, staying home from school or allowing special access to television or games). Instead, encourage normal activities and give them positive feedback for participating and making progress toward good health.

-Avoid labeling your child as "sick" or framing the condition as a "chronic illness," which can increase anxiety. Instead, tell them that occasional discomfort is normal.

●Therapist-led – In addition to the above, some children will benefit from special techniques that can be taught by a therapist. Examples include:

•Coping skills – Coping skills are purposeful efforts to manage one's own emotions, thoughts, and behaviors in response to stressful events or circumstances. These techniques can reduce a person's experience of stress, including pain. A pediatric therapist can teach your child coping skills that are appropriate for their age.

•Relaxation techniques – Older children and adolescents with a DGBI can learn muscle relaxation techniques such as deep breathing exercises (table 2). Once your child learns these techniques, they should try to use them when they are feeling pain and also practice them for 10 minutes at least twice every day. If needed, you can "coach" them during these sessions.

•Guided imagery/hypnotherapy – These are distraction techniques in which a trained therapist guides a child into a focused state of awareness and deep relaxation. The technique uses suggestion, imagery, and relaxation to calm the digestive tract and avoid focusing on discomfort. Gut-directed hypnotherapy can be used for children as young as six years old and has been shown to have long-lasting benefits on reducing pain frequency and intensity.

•Cognitive behavioral therapy (CBT) – CBT is a therapy approach that helps a person identify and understand the connection between thoughts, feelings, and behaviors (including the experience of pain). This typically includes a combination of education, relaxation techniques, and stress management. For example, the therapist might ask your child to describe or record their thoughts when the pain is happening, then identify any thoughts that might not make sense. Then, the therapist helps your child find a good strategy for responding to the pain (such as the distraction techniques described above) and has them practice the skill during therapy sessions.

Other behavioral techniques that may help some children with chronic abdominal pain include yoga and biofeedback, but there is less evidence to support these.

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

Management of triggers — You may be able to identify triggers that seem to make your child's pain worse or better by keeping a record of your child's symptoms (form 1).

Anxiety — Keep an eye out for situations that might make your child feel anxious, especially if they seem related to the pain episodes. Common sources of anxiety that might trigger abdominal pain are school, some social interactions, stress at home, or specific fears. Keeping a pain diary might help you identify or confirm certain triggers. For example, you might notice that your child is more likely to have pain on weekday mornings (before school) than on weekends.

If anxiety seems to be a trigger for your child's pain symptoms, there are several approaches to treatment. Giving them reassurance might be enough. Or, if the symptoms are interfering with normal activities, it might help for them to talk to a counselor or have CBT. If the anxiety is related to school, it is important to have them return to school, with supports to address any specific concerns, rather than staying home from school. Staying home often makes the problem worse in the long run. (See 'Behavioral approaches' above and 'Return to school' above.)

Sleep — Having trouble falling asleep and staying asleep, short sleep duration, and feeling sleepy during the day may contribute to abdominal pain. If your child has any of these problems, it is important to discuss this with your health care provider.

Dietary triggers — Dietary restrictions are not routinely recommended for children with chronic abdominal pain, because they are not consistently helpful, can lead to nutrient deficiencies, and may increase anxiety related to eating. Also, food allergies are very uncommon in children with typical symptoms of functional abdominal pain. Therefore, it's important to talk to your child's health care provider before making any dietary changes.

However, if your child's pain seems to be related to a specific dietary trigger, you may discuss with your child's health care provider whether a short trial of restricting that type of food could be helpful. Possible food triggers for chronic abdominal pain include:

●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 ease these symptoms; this is done by eliminating milk and milk products or by using lactase enzyme replacement (eg, Lactaid milk, Lactaid drops). Talk to your child's health care provider before doing a trial of completely removing dairy products from their diet; they can help make sure that your child continues to get the nutrients they need, including calcium and vitamin D. If abdominal pain does not get better after two weeks of lactose restriction, the child should restart milk and milk products. There also are tests for lactose intolerance, which can be used if the diagnosis remains uncertain.

●Fermentable sugars and FODMAPs – FODMAPs stands for "fermentable oligosaccharides, disaccharides, monosaccharides, and polyols." These types of short-chain carbohydrates (sugars) may be poorly absorbed by the small intestine, leading 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 some 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 was associated with some improvement in gastrointestinal (GI) symptoms (eg, bloating, nausea). The low-FODMAP diet is complex and difficult to adhere to and should be managed by a dietitian.

●Gluten – A gluten-free diet is appropriate and necessary only for children with diagnosed celiac disease or with gluten allergy. For children with functional abdominal pain, a gluten-free diet is generally not recommended. Although gluten-free products have become increasingly popular and more widely available, a gluten-free diet is unlikely to improve symptoms. Screening for celiac disease can be performed with blood testing by your child's health care provider, but it is important to note that results may not be accurate if the child has already started a gluten-free diet. (See "Patient education: Celiac disease in children (Beyond the Basics)".)

●Other foods and drinks – Other common dietary triggers include:

•Citrus

•Caffeine

•Spicy foods

•Certain sugar substitutes (erythritol or xylitol, which are found in sugar-free candy or gum)

•Certain fruits and juices that have natural sorbitol (prune, pear, cherry, and, to a lesser extent, apple)

•Gas-producing foods (eg, beans, onions, celery, carrots, raisins, bananas, apricots, prunes, Brussels sprouts, wheat germ) (see "Patient education: Gas and bloating (Beyond the Basics)")

Medicines — Medicines that can cause upset stomach include nonprescription pain medicines such as aspirin and ibuprofen (sample brand names: Advil, Motrin). Some prescription medicines also might cause abdominal pain (with or without diarrhea or other side effects). If your child is regularly taking a medicine, talk with their health care provider to see if the abdominal pain might be related to the medicine.

Supplements, medicines, and other interventions — In addition to the steps outlined above (returning to school, behavioral approaches, and management of triggers), your child might benefit from trying one or more of the following. Although their benefit is not well proven, they have low risk of harm. You can discuss these options with your child's health care provider:

●Probiotics – Probiotics are sometimes called "friendly bacteria" or "good bacteria." They are bacteria that live in the intestine and help it work well. Probiotics can also help defend the body from infections caused by unfriendly bacteria or other germs. All healthy people have these probiotic bacteria in their intestine, so there's no need to take anything extra. But some people take pills that contain probiotics to add more of these bacteria to their intestine.

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

●Fiber – If your child has constipation or constipation-predominant IBS, they might benefit from 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. The fiber makes the stool softer and helps it move through the GI tract.

●Other treatments for constipation – If your child has frequent or severe constipation, a stool softener or other laxative might help. If they are having stool accidents (ie, soiling) along with severe abdominal pain, they may benefit from a "cleanout" treatment. (See "Patient education: Constipation in infants and children (Beyond the Basics)".)

●Peppermint oil – Peppermint oil (available commercially) is thought to decrease muscle spasms in the GI 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 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 with abdominal pain.

●Medicines – Medicines might be needed for some specific causes of abdominal pain. (See 'Other possible diagnoses' above.)

Nonprescription ("over-the-counter") medicines for stomach acid or stomach upset are available. It's a good idea to talk with your child's health care provider before trying these, especially if your child is taking these medicines frequently (more than a few doses a month). This is also true for certain types of laxatives (used for constipation).

WHEN TO SEEK HELP — 

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 longer than one hour, or severe pain that comes and goes and lasts longer than 24 hours

●Refusing to eat or drink anything for a prolonged period

●Fever higher than 102.2°F (39°C), or fever higher than 101°F (38.4°C) for more than three days

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

●Behavior changes, including lethargy or decreased responsiveness

Parents and caregivers should call the 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 fewer 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)
Patient education: Flank pain (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

Websites — The following organizations also provide reliable health information.

●American Academy of Pediatrics (healthychildren.org)

•Abdominal pain (www.healthychildren.org/English/health-issues/conditions/abdominal/Pages/default.aspx)

•Disorders of gut-brain interaction (www.healthychildren.org/English/health-issues/conditions/abdominal/Pages/Stomachaches-in-Children-Teens.aspx)

●National Library of Medicine

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

●University of Michigan Child Development and Behavior Resources

•(www.uofmhealth.org/health-library/sig244830)

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