Abdominal Pain in Children

Abdominal pain in children is one of the most common reasons parents bring children to a hospital’s emergency department. The evaluation of a "tummy ache" can be challenging for both parents and the doctor.

Possible causes for a child’s abdominal pain range from trivial to life threatening, with little difference in the child's complaints. Fortunately, most often abdominal pain in children gets better quickly. The difficulty for a parent or caregiver lies in deciding which complaints need emergency care and which do not.

• Infections: Viruses or bacteria can cause abdominal pain, as seen in typical stomach flu or gastroenteritis. Viral infections tend to go away quickly, while bacterial infections may need an antibiotic to get better.
  
  
• Food related: Food poisoning, which acts like a stomach flu, food allergies, excess food ingestion, and gas production all can cause bloating and temporary discomfort.
  
  
• Poisoning: This can range from simple problems such as eating soap to more serious issues such as swallowing iron pills.
  
  
• Surgical problems: These include appendicitis and blockage of the bowels.
  
  
• Medical causes: Things outside the abdomen can cause pain there. For example, a child can have abdominal pain with diabetic problems or with a black widow spider bite.

A parent or caregiver usually can notice pain in a child’s abdominal area. In infants and very young children you may see crying, facial expressions of pain, and curling up. Toddlers usually will be quick to tell you what is wrong. Some teenagers may be reluctant to report pain, and you must try to get a clear explanation of what they are feeling. Ask about these conditions:

• Duration of the pain: An important thing to remember is that most simple causes of abdominal pain do not last very long. Most of us have had gas pains or the stomach flu and remember that the pain was usually gone in 12-24 hours. For this reason any abdominal pain that continues should be a reason to contact a doctor.
  
  
• Location of the pain: Most simple pains are located in the center of the abdomen. The child will rub around his or her belly button. Pain that is felt in other areas is of more concern. This is especially true of pain that is low down on the right side of the abdomen. Pain in that area is appendicitis until proven otherwise.
  
  
• Appearance of the child: As a general rule, if the child looks very ill in addition to being in pain, medical help should be sought. Most often the caregiver can "just tell" the child is very sick. But things to look for with abdominal pain are a pale appearance, sweating, or a child who is sleepy or listless.
  
  
• Vomiting: Children vomit quite frequently with abdominal pain, and this does not mean there is a serious problem. However, as with the duration of the pain, most simple causes of vomiting go away very quickly. The same rule applies: Vomiting over 12-24 hours is a reason to call the doctor.
  
  
• Nature of the vomiting: In infants and very young children, vomiting that is green or yellow is a reason to call the doctor. At any age, vomiting that appears to contain blood or darker material is a reason to seek emergency care.
  
  
• Diarrhea: This is also very common with abdominal pain and usually indicates that a virus is the cause. This can continue for several days but usually only lasts 1-3 days. Any blood in the stool is a reason to seek medical care.
  
  
• Fever: The presence of fever does not mean there is a serious problem. On the other hand, a normal temperature can be seen with some of the bigger problems causing abdominal pain.
  
  
• Groin pain: One serious problem that a boy may describe as abdominal pain really comes from somewhere else. It is testicular torsion, a condition in which a testicle twists on itself and cuts off the blood supply. The child may be embarrassed to mention the location, so you should ask if there is any pain "down there." A testicular problem is easy to fix if treated early enough. So if a child complains of pain in the groin area or testicles, seek medical care.
  
  
• Urine problems: Abdominal pain associated with any trouble urinating, such as painful or frequent urination, could indicate an infection and is a reason to seek medical care.
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• Rash: There are certain serious causes of abdominal pain that occur with a rash. The combination of the two is a reason to contact your doctor.

Abdominal pain in children has several potential causes covering various organ systems, each with a unique set of tests. The doctor will conduct a thorough history and physical exam, which likely will include a rectal exam to evaluate for blood. From this information the doctor may order additional tests.

• Blood probably will be drawn and sent to a lab for tests— blood count, liver function tests, blood cultures, amylase/lipase, lead level. A urine sample may be obtained and sent for urinalysis and culture.
  
  
• A stool sample may be obtained to check for blood, bacteria, or parasites.
  
  
• X-rays may be taken to evaluate the abdomen.
  
  
  • Ultrasound of the abdomen/testicles
    
    
  • CT scan of the abdomen
  
  
• Special tests, such as a barium enema or swallow, anal manometry, or a pelvic exam, may be ordered based on the child's condition.
  
  
• A specialist such as a gastroenterologist or a general pediatric surgeon may be consulted.

|Self-Care at Home|

A parent or caregiver must be observant and should contact appropriate help at the appropriate time. Monitor a child especially closely during recovery until the child is better. A teenager may not want to be bothered but still should be checked on.

• Rest: A child with active abdominal pain often will benefit from resting. Lying face down may help relieve gas pain, but the best position to lie in is the one that feels best to the child.
  
  
• Diet: People can survive a long time without solid food but need to keep up on liquids. Dehydration takes time to develop, so forcing fluids is not always necessary. A child who is actively vomiting will not be able to hold down a large amount of liquid. Doctors recommend giving small amounts (1-2 ounces) at a time until the child can handle more.
  
  
• Fluids to give: Do not give water or boiled milk to infants because it can cause serious problems with the salt content of their bodies. Doctors recommend juices or the various dehydration liquids, for example Pedialyte, that you can buy over-the-counter. Try to get infants back on their usual feedings as soon as possible. Good choices for older children include juices, electrolyte drinks such as Gatorade, soups, and broth. If older children ask for soft drinks, avoid those with caffeine.
  
  
• Solid foods: In general a child will let you know when it is time to get back on solid food. Start them slowly, first with toast or crackers, and advance to regular foods if they tolerate the feedings.
  
  
• Medications: You can use acetaminophen (Aspirin Free, Children’s Silapap, Panadol, Liquiprin, Tylenol) to lower the fever. Most doctors still avoid aspirin in children. Do not use antibiotics unless prescribed by a doctor. Physicians do not recommend herbal medicines or other home remedies. If you use them and later see a doctor, be sure to say what you gave the child, because it could affect the treatment.

|Medical Treatment|

Treatment will be prescribed according to the history, physical, lab results, and the individual child. Treatment may be as simple as sending the child home with instructions for rest, encouraging fluids, and eating a bland diet. Treatment can be as extensive as hospital admission and surgery.

|Outlook|

The prognosis for abdominal pain in children is as diverse as the causes themselves. Abdominal pain identified and treated early carries a good prognosis overall. Pain undiagnosed and untreated can be life threatening. Consequently, early in the child's illness, a parent or caregiver should work with the pediatrician and hospital to ensure the child receives appropriate care.

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Author: David J Watts, MD, Staff Physician, Department of Emergency Medicine, Temple University School of Medicine.

Coauthor(s): Robert M McNamara, MD, FAAEM, Professor of Emergency Medicine, Temple University; Chief, Department of Internal Medicine, Section of Emergency Medicine, Temple University Hospital.

Editors: Scott H Plantz, MD, FAAEM, Research Director, Assistant Professor, Department of Emergency Medicine, Mount Sinai School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, ; Anthony Anker, MD, FAAEM, Attending Physician, Emergency Department, Mary Washington Hospital, Fredericksburg, VA.