Many children complain of abdominal pain, and we see many either through the Paediatric Emergency Department or via Outpatients.
We would consider chronic abdominal pain to be > 3 episodes of abdominal pain over the time period of 3 months or more, affecting daily activities. This applies to children over 3 years of age. Functional abdominal pain is a very common problem in children with an estimated prevalence of 10-14% in the UK. This review from the Archives of Disease in Childhood is very helpful in deciding who to investigate further:
https://ep.bmj.com/content/98/1/32
History
It is important to establish the nature, duration and location of any abdominal pain. Central, peri-umbilical pain with no radiation is less likely to be pathological than pain that is localised or radiates. Associated bowel disturbance or urinary symptoms should be elicited. A family history of inflammatory bowel disease or renal disease is important to note.
You should establish the impact of pain on daily functioning and a pain diary can be helpful in this. Any exacerbating or relieving factors should also be documented. This should include an assessment of any socio-emotional stressors affecting the child or young person.
In pubertal girls, it is important to discuss their menstrual cycle – whether this is related to the pain, its regularity and heaviness of bleeding. A history of sexual activity should be taken, in an appropriately confidential way. Pregnancy should be ruled out using urine βHCG. Any allegation or suspicion of child sexual abuse should be taken seriously and concerns should be raised through safeguarding processes.
Examination
A recent height and weight should be plotted in the Red Book, or appropriate age-specific centile chart.
Abdominal examination should be performed. Inspection of external genitalia is also important, considering torsion of testes as an important differential in boys.
Some children can present with respiratory pathology complaining of upper abdominal pain, so it is important to have also performed a respiratory systems examination, auscultating carefully at the lung bases.
If there are symptoms of urinary tract infection (suprapubic pain, dysuria, fever, frequency), a urine dipstick should also be performed.
The ‘red flags’ for abdominal pain are:
1. Involuntary weight loss/faltering growth
2. Gastrointestinal bleeding (usually per rectum without evidence for fissure)
3. Chronic, severe diarrhoea or vomiting (some vomiting can occur in functional abdominal pain)
4. Persistent right upper quadrant or right lower quadrant (RLQ) abdominal pain
5. Unexplained fever
6. Family history of inflammatory bowel disease (IBD)
7. Jaundice
8. Urinary symptoms, back or flank pain (urine dipstick and MC&S also helpful)
9. Abnormal examination findings
If any of these are present, please consider whether they need to be seen on the same day – if so, please discuss with the PAU phone, via switchboard.
If you think they can be seen in an urgent outpatient appointment, please email the referral to khft.paediatric-rapidaccessreferrals@nhs.net. These are triaged for urgency by a Consultant so please give details of any ‘Red Flags’ present.
If none of these red flags are present, there is little evidence for performing investigations. Abdominal ultrasound for children with no ‘red flags’ identifies pathology in less than 1%. The investigations that we would recommend are a FBC (to check for anaemia) and a coeliac screen (anti-transglutaminase antibodies and IgA). Coeliac screen is only helpful if the child is eating sufficient amounts of gluten in their diet.
In children with functional abdominal pain and normal FBC and coeliac screen, we usually recommend reassurance and education to help manage the symptoms. The pain felt is real, in the same way that a headache might hurt, but usually has no underlying pathology. In some children, stress and anxiety can contribute to their ability to cope with pain, and finding ways to assist with this can be helpful. Using relaxation or mindfulness techniques has been shown to help manage chronic pain.
For children with any of the ‘Red Flags’, please consider whether they need to be seen on the same day – if so, please refer urgently via the PAU telephone for review on PAU.
If they have any ‘Red Flags’ but you feel they can wait for an urgent OP appointment, please send a referral via ERS marked urgent. These are triaged for urgency by a Consultant so please give details of any ‘Red Flags’ present.
If you would like to discuss further, either because you are unsure of urgency or because they have no red flags, but you would feel they would still benefit from paediatric review, please contact us via Advice & Guidance on ERS to discuss. Some families will still need to see a Paediatrician despite not having any of the ‘Red Flags’ to help discuss the problem and find ways of managing pain, especially if it is affecting school attendance or daily functioning. It is helpful to have an accurate record of school attendance, which can be obtained from the school office, to gauge the effect of pain on school attendance.
It is also helpful to keep a ‘pain diary’ so please ask the family to document one in advance of any outpatient appointment with us. An example can be found and downloaded here:
https://www.uptodate.com/contents/image?imageKey=PI%2F66570
