Recurrent Abdominal Pain in Children

 

Am Fam Physician. 2018 Jun 15;97(12):785-793.

Author disclosure: No relevant financial affiliations.

Recurrent abdominal pain (RAP) in children is defined as at least three episodes of pain that occur over at least three months and affect the child's ability to perform normal activities. RAP is most often considered functional (nonorganic) abdominal pain, but an organic cause is found in 5% to 10% of cases. Further workup is warranted in children who have RAP and fever, vomiting, blood in the stool, more than three alarm symptoms, or a history of urinary tract infections. Physical examination findings that should prompt further workup include weight loss or failure to grow; jaundice; costovertebral tenderness or back pain with lower extremity neurologic symptoms; liver, spleen, or kidney enlargement; an abdominal mass; or localized tenderness on abdominal examination. Workup may include complete blood count, erythrocyte sedimentation rate, C-reactive protein level, fecal guaiac testing, fecal ova and parasite testing, or urinalysis. Pregnancy testing and screening for sexually transmitted infections should be considered in adolescents or if there are concerns about sexual abuse. Abdominal radiography can be helpful for diagnosing obstruction or constipation. Abdominal ultrasonography identifies an abnormality in up to 10% of children with RAP who meet criteria for further workup, compared with 1% of those who do not meet these criteria. Functional abdominal pain is a clinical diagnosis and no workup is needed. Management of functional abdominal pain focuses on improving quality of life, reducing parent and child concerns about the seriousness of the condition, and reducing the disability associated with pain rather than complete resolution of pain. Although evidence is lacking for most pharmacologic treatments of functional abdominal pain, psychological therapies such as cognitive behavior therapy and hypnotherapy have been shown to be beneficial.

There are a variety of terms used for recurrent abdominal pain (RAP) in children (Table 1).1,2 RAP is a descriptive term and not a diagnosis, and it has been defined as at least three bouts of pain occurring over at least three months that are severe enough to affect daily activities.3 It accounts for up to 5% of primary care visits.4

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Functional abdominal pain is a clinical diagnosis and therefore does not require a diagnostic workup.

C

1

Alarm symptoms and laboratory and diagnostic workup findings do not reliably distinguish organic from nonorganic disease in children with recurrent abdominal pain. However, organic disease is suggested by the presence of fever, vomiting, blood in the stool, more than three alarm symptoms, or history of urinary tract infections.

C

1, 12

For all types of recurrent abdominal pain in children, the primary goals of management are improving quality of life, reducing parent and child concern about the seriousness of the condition, and reducing disability associated with pain rather than complete resolution of pain.

C

30

In children with functional abdominal pain, the use of probiotics, such as Lactobacillus, reduces the intensity and frequency of abdominal pain and is safe in children.

B

9, 31

Cognitive behavior therapy and hypnotherapy improve abdominal pain in children with functional abdominal pain disorders.

B

31


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Functional abdominal pain is a clinical diagnosis and therefore does not require a diagnostic workup.

C

1

Alarm symptoms and laboratory and diagnostic workup findings do not reliably distinguish organic from nonorganic disease in children with recurrent abdominal pain. However, organic disease is suggested by the presence of fever, vomiting, blood in the stool, more than three alarm symptoms, or history of urinary tract infections.

C

1, 12

For all types of recurrent abdominal pain in children, the primary goals of management are improving quality of life, reducing parent and child concern about the seriousness of the condition, and reducing disability associated with pain rather than complete resolution of pain.

C

30

In children with functional abdominal pain, the use of probiotics, such as Lactobacillus, reduces the intensity and frequency of abdominal pain and is safe in children.

B

9, 31

Cognitive behavior therapy and hypnotherapy improve abdominal pain in children with functional abdominal pain disorders.

B

31


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert

The Authors

show all author info

CARIN E. REUST, MD, MSPH, is an associate professor in the Department of Family and Community Medicine at the University of Missouri School of Medicine in Columbia....

AMY WILLIAMS, MD, MSPH, is an assistant professor in the Department of Family and Community Medicine at the University of Missouri School of Medicine.

Address correspondence to Carin E. Reust, MD, MSPH, University of Missouri, MA 303 HSC, Columbia, MO 65212 (e-mail: reustc@health.missouri.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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