Referrals pathways for Regional Paediatric model
Abdominal pain, both acute and chronic, is extremely common in children, with many and varied differential diagnoses.
For the management of acute abdominal pain, please refer to the Royal Children’s Hospital clinical practice guidelines. Acute abdominal pain will not be discussed further below.
Chronic abdominal pain needs to be considered in the context of the child’s psychosocial environment, given the most common diagnoses of ‘functional’ or ‘non-specific’ abdominal pain are the leading causes of presentation to specialist services.
Chronic abdominal pain is common in childhood, with the underlying diagnosis not often one of serious medical concern. However, abdominal pain remains a large cause of concern for families and needs to be considered in both an age-appropriate diagnostic categorization as well as consideration of psychosocial factors.
Differentials (not an exhaustive list)
- Perceived abdominal discomfort is common in infancy, with many normal symptoms being attributed to a pain response such as flexing the legs upwards, persistent crying and back arching. See Infant Irritability for further information.
- Constipation is a common parental concern in infancy. Babies will quite normally push, strain, grunt and turn purple for some time before passing bowel actions. It is normal for infants to have between 7 stools every day to one stool every 7 days (or for formula feed babies, 3 stools every day to one stool every 3 days). The consistency of the stool is more important when making the diagnosis of constipation in infancy (see constipation for more detail).
- Urinary tract infection can present in an indolent fashion in younger children, often without fever, and can be quite chronic in presentation.
- Constipation remains a common cause of abdominal pain in children (see constipation for further information).
- Urinary tract infection (see above)
- Celiac disease has a peak presentation from 6 months to 2 years, and is often associated with bloating and bowel habit changes (see celiac disease for more detail).
- Helicobacter pylori infection should be considered in crowded living environments, particularly with lower SES families.
- Chronic GIT infections are not as common as some may attribute; beware diagnosing this as the cause of abdominal symptoms when stool M/C/S reveal opportunistic, largely non-pathogenic organisms (e.g. Blastocystis hominis).
- Gastritis causes pain which is largely post-prandial or associated with certain foods, seen in children generally after viral infections.
- Inflammatory bowel disease is uncommon in children, although can be seen as young as 12 months (especially Crohn’s disease); generally presents with at least 6 weeks of symptoms including bloody or mucousy stools.
- Abdominal migraine can be seen in children, presenting with episodic severe abdominal pain, often associated with nausea +/- vomiting as well as headache (although not always).
- Diabetic ketoacidosis (see diabetes for more detail).
- Functional or non-specific abdominal pain is a common diagnosis (up to 10-15% of adolescents) in this age group, and although it remains a diagnosis of exclusion, history and a normal examination will often guide you towards this.
- Constipation remains a common cause of abdominal pain in adolescence (see constipation for further information).
- Irritable Bowel Syndrome is also a diagnosis of exclusion.
- Chronic GIT infections (see above)
- Gastritis (see above)
- Inflammatory bowel disease (see above - more commonly presents in adolescence)
- Urinary tract infection
- Gynaecological problems such as ovarian pathology, PID, etc. (see RCH CPG)
- Abdominal migraine (see above)
- Diabetic ketoacidosis (see diabetes for more detail).
- Renal calculi
- Chronic abdominal pain is a common presentation in childhood, often without a severe underlying pathology.
- Perceived infant abdominal discomfort often represents physiological irritability.
- Functional or non-specific abdominal pain is a common diagnosis in adolescence, as well as in younger children.
- There are no ‘standard’ investigations for chronic abdominal pain, consider each test based on relative yield after a thorough history and examination.
A thorough history and examination will be invaluable in excluding many of the more serious causes of abdominal pain, often preventing or limiting the need to progress to further investigations or referral.
There are no ‘standard’ investigations for chronic abdominal pain.
Initial investigations to consider (less likely in neonates) – consider each test based on relative yield given history and examination:
- UEC, LFT, lipase/amylase
- FBE, CRP, ESR
- Celiac screen & total IgA
- Urine M/C/S
- Faecal M/C/S (careful with interpretation of which organisms are truly pathogenic!)
- Faecal H. pylori antigen (faecal antigen testing is the most sensitive marker of H pylori infection in children and is not persistent after treatment).
- Faecal calprotectin (useful for screening for IBD)
- Abdominal USS (often negative, consider with gynaecological concerns, right upper quadrant concerns)
- Further abdominal imaging is rarely indicated and seldom helpful; CT scans are not generally useful in childhood abdominal pain and infer a large radiation dose.
Management of chronic abdominal pain will depend on the underlying cause.
Consider non-pharmacological measures when functional or non-specific abdominal pain is considered (e.g. reassurance and explanation, relaxation, massage, heat packs, organize review).
Beware of offering escalating analgesics and other symptom relief medications in chronic abdominal pain without an identifiable cause given that non-specific abdominal pain is unlikely to completely respond.
- Referral to paediatric outpatient services is not generally required for chronic abdominal pain unless there are significant persistent concerns. It is not appropriate to presume further referral for paediatric gastroenterology opinion and endocscopy will be undertaken, as very few cases of chronic abdominal pain require this.
- Psychology services should be considered with functional or non-specific abdominal pain.