by Frank R. Sinatra, M.D.
Professor of Pediatrics
University Of Southern California School of Medicine
Head, Pediatric Gastroenterology
Women's and Children's Hospital
Los Angeles+USC Medical Center
Definition of Recurrent Abdominal Pain: Three or more episodes of abdominal pain, severe enough to affect the child's activities, occurring over a period of more than three months. (J. Apley).
Recurrent abdominal pain (RAP) is the most common chronic abdominal pain disorder in pediatrics, affecting up to 10% of school age children. Although distressing for both child and parents, RAP is seldom due to a serious medical condition.
Typical bouts of RAP consist of cramping or dull aching pain usually located in the area around the "belly button." Most episodes last several minutes to an hour or more and resolve without specific treatment. Episodes are frequently associated with a pale skin color, sweating and occasionally vomiting, loose stools or headache. During pain-free periods the child is healthy-appearing, is able to eat and grow normally and is able to participate in normal activities.
The cause (or causes) of the abdominal pain is not known but many children seem to have abnormal movement of intestinal contents through the small and large bowel ("motility disorder") or an exaggerated painful response to normal intestinal movements. Intestinal movement is controlled by a complex interaction of hormones and an extensive intestinal nervous system. Since the intestinal nervous system ("little brain") and the central nervous system ("big brain") are intimately connected, physical and emotional "stress" can initiate or perpetuate attacks of abdominal pain. It is important to note that the use of the term "stress" does not always mean unpleasant events. Although school work, athletic events or family problems can certainly produce "stress", for many children the excitement of play or an eagerly awaited event (birthday party, trip to Disneyland, etc.) can trigger a pain episode. Perhaps the best way to understand the connection between activities and abdominal discomfort is to imagine the "gut feeling" most people experience after a sudden scare, during an exciting game or movie, or after viewing or hearing of a particularly unpleasant event.
Unfortunately, RAP (sometimes called "irritable bowel syndrome") cannot be diagnosed by blood, urine or x-ray tests. The diagnosis is made by a careful medical history and physical examination. Tests should be reserved for situations where the symptoms are atypical or the physical examination suggests an alternative possibility. The fact that tests do not reveal a specific chemical or anatomic disorder does not mean that the pain is imaginary or "in the head." Although some children may learn to use these episodes to avoid school or other responsibilities, the pain should be regarded as "real pain."
Treatment needs to include reassuring the child that he/she does not have a serious disorder but that you understand how much discomfort the child is feeling. During acute attacks, many children will benefit from lying down for a short period of time in a quiet, dark, cool area where stimulation is minimal. This will promote relaxation and when used at the beginning of an episode may prevent, or decrease the severity, of the attack. Some children will benefit from a high fiber diet or the use of fiber supplements. This is particularly important in a large group of children who do not adequately empty their large bowel on a regular basis ("functional fecal retention"). Improving stool elimination will dramatically decrease the number and severity of pain episodes in this type of patient. So-called "anti-spasmodic" medications should be avoided. These drugs are seldom effective, have significant potential side effects, and may actually worsen the pain episodes. Above all, regular school attendance should be encouraged and the child should not be sent home from school unless the attack is prolonged (over 1 hour in duration) or unusually severe.
There are numerous disorders capable of producing recurrent abdominal in children, and parents are frequently concerned that "something is being missed." It should be reassuring to both parents and pediatricians that, in contrast to adults, intestinal cancer in children is extraordinarily rare. Children can, however develop RAP in association with ulcer disease, esophagitis, inflammatory bowel disease, lactose intolerance, parasitic infestation (especially giardiasis) as well as a number of less common disorders. Your pediatrician will be able to tell you if these problems need to be considered. "Red flags" that require evaluation by your pediatrician are shown below. It is also important that you contact your pediatrician for any unusual episodes. Acute appendicitis may occur at any age and may occur in children with a long history of RAP.
Chronic abdominal pain is a distressing, but seldom serious problem. The major goal for parents should be to help their child in minimizing the effect of the pain episodes on their daily activities. Your pediatrician will be able to help you accomplish this goal.
Pain consistently located in an area away from the "belly button"