Dr.ª Rute Gonçalves

Pediatrician 

Abdominal pain during pediatric age

HPA Magazine 14

Abdominal pain is a very common symptom in the pediatric age, from small infants to teenagers, with a peak during preschool and school going age. It is one of the most common reasons for being referred to the Pediatric Emergency Unit. 
The causes are diverse and can be classified into Organic and Functional. 
Organic Causes are those where a physical cause is found and can encompass a wide spectrum of severity, from esophagitis; gastric or duodenal ulcer; inflammatory bowel disease; urinary infection; acute appendicitis, among others.

In this case, the child's medical history, specifying symptoms, the type of pain and its location, may be sufficient for an organic cause to be suspected. For an accurate diagnosis, some complementary diagnostic tests may be required. There include blood and stool tests as well as imaging tests, such as abdominal ultrasound and more invasive tests such as upper and lower digestive endoscopy (colonoscopy), performed under sedation, with the support of an Anesthesiologist.
Some symptoms are suggestive of organic abdominal pain, namely:

• Abdominal pain in a child under the age of 2 years;
• Pain in a specific region, other than the peri-umbilical area (around the navel);
• Pain that awakens the child during the night;
• Pain together with vomiting and/or prolonged diarrhea;
• Weight loss, significant decrease in appetite, delay in structural growth;
• Blood in the stool; vomiting with blood;
• Recurrent oral thrush;
• Among these organic causes, I must highlight the most common: celiac disease (gluten intolerance); Helicobacter pylori infection; inflammatory bowel disease (Crohn's disease and ulcerative colitis).

Functional Gastrointestinal Diseases they exist in pediatric and adult age and are usually diagnoses once other diseases are excluded. That is, even if the clinical history suggests this diagnosis, some tests are necessary to exclude an ORGANIC cause. The following pathologies are of a FUNCTIONAL cause: 

• Colic and functional regurgitation in infants - typical in infants up to 6 months;
• Functional constipation;
• Functional abdominal pain;
• Irritable bowel syndrome;
• Cyclic vomiting syndrome; 
• Aerophagia;
• Functional dyspepsia.

I must emphasize that constipation, which in more than 90% of cases is functional, that is, it is not based on a specific gastrointestinal disease, but is related to functional characteristics of each individual’s intestinal transit. It has some family predisposition and is the most common cause of referral to a pediatric gastroenterology consultation due to recurrent abdominal pain.
Difficulty in defecating and a decrease in the number of stools per week (less than 3) or very hand stools (Bristol classification - type 1 and 2).
There are 3 critical phases for the onset of constipation during a child’s development:
1 - During infancy when cereals are introduced (dairy or non-dairy porridge);
2 - During the potty training phase (2-3 years);
3 - Beginning of school going age (5-6 years).
The potty-training phase between 24 and 36 months. Constipation during this phase is due to the child's fear of anal pain during defecation, leading to maneuvers of retention and difficulty in changing from the diaper to the potty.
Often negative experiences with defecation (pain when defecating; being forced to sit on the toilet even when scared; use of rectal therapy; presence of blood in the stools) due to the refusal to defecate, leading to the accumulation of fecal mass in the rectum and subsequently anal and abdominal pain, thus begins a vicious cycle.
Dietary errors (excess of carbohydrates and sugars) associated with a diet low in vegetables and fresh fruit are the main cause of constipation.
The treatment involves a lot of teaching and training (sitting position on the toilet with a foot support; encouraging the child to sit on the toilet at set times; demystifying fear; reassuring), changing wrong eating habits and taking laxative treatment.
Several drugs are available on the market that can be taken orally (syrup or powder to dissolve) that have virtually no side effects, are palatable, are not habit forming as far as the gastrointestinal system is concerned and are effective, avoiding rectal therapy. Enemas should only be used in emergency situations, as they increase the anxiety associated with this clinical situation.
FUNCTIONAL abdominal pain remains an enigmatic clinical situation! The child feels the pain, but there is no obvious organic cause. It has a higher incidence between the ages of 5 to 10 years. It often requires extensive and unnecessary investigations.
Various documented therapies are proposed with little effect and little evidence of their benefit.
 

Unlike ORGANIC pain, FUNCTIONAL pain has benign characteristics. This pain is not constant, does not usually interfere with the child's daily activity, has a peri-umbilical location, does not lead to decreased appetite and is often related to the school going period.
Probiotics or antispasmodics can be used, but the most effective treatment involves psychological support, more specifically with cognitive-behavioral therapy. The key to solving this situation, which can be slow, is to reassure the parents and the child. Explaining that it is a benign situation. The pain that the child refers to, should be valued, but parents and child minders should try to calm the child down and offer him / her distraction strategies. Do not alter the child's usual routine.
Naturally, this diagnosis is reached by EXCLUSION, that is, although the clinical history is suggestive, some auxiliary tests should be performed, such as: laboratory analysis tests including celiac disease study; to exclude anemia; urinary infection; intestinal parasites, among others.
Abdominal pain in pediatric age is in most cases of benign aetiology, but a detailed clinical history is essential for a better understanding of the condition and may avoid the need for invasive exams.