Chronic Abdominal Pain In Children — Part 1: Awareness Of The Challenge

As a pediatric gastroenterologist, many children whom I see in my practice experience chronic abdominal pain. Children with this disorder have belly pain that often comes and goes and lasts longer than 2 months. Understandably, children and their parents want to know what is causing the pain, if it is serious, and what can be done about it. Fortunately, the vast majority of children do not have a serious or life threatening problem. Instead, as I will explain, most have a condition called functional abdominal pain (FAP). FAP is a very common disorder affecting 1 out of 5 children and adolescents, not only in the United States, but throughout the world. There are many ways that we can help children with FAP.

How does my doctor diagnose FAP?

FAP usually can be diagnosed based on the parent and child descriptions of the symptoms, a physical examination of the child, and sometimes, a few simple tests (for example, looking for blood in the stool). The American Academy of Pediatrics states that most children who are brought to the physician’s office for chronic (functional) abdominal pain are unlikely to require diagnostic testing. If testing is done, it usually can be carried out in the pediatrician’s office and usually turns out to be normal. The decision whether or not to do testing and how much testing to do may pose a challenge for families of children with FAP and the health team members helping to care for them as recently described by Dr. Perri Klass in the New York Times. When a pediatrician, pediatric nurse practitioner, or pediatric gastroenterologist is evaluating a child for possible FAP, they are taught to look for “red flags” — signs that point to the problem possibly being something other than FAP. These “red flags” include weight loss, persistent fever, significant diarrhea or vomiting, rashes, blood in the stool, and/or a family history of a serious gut problem. If a “red flag” is present, more testing may be carried out. If there are no “red flags,” the physical examination is normal, and the history of the pain fits, we can make a diagnosis of FAP confidently.

Why should we pay attention to FAP?

Children with FAP generally have a poorer quality of life in comparison to their healthy peers and even to other children with gut problems like inflammatory bowel disease. As a pediatric gastroenterologist I may see this manifest as missing school or being unable to participate in activities such as sports. Statistics suggest that up to 2 out of 3 of children with FAP may go on to become adults with the same symptoms, meaning some of my adult gastroenterology colleagues are likely to be seeing a few of my patients years down the line for the same problem. That is, unless we can better address this problem in childhood!

I’ve heard the terms irritable bowel syndrome and functional dyspepsia used. What are these?

In addition to having belly pain, some children with FAP may also have changes in their stools or stooling pattern. For example, sometimes the pain will get better after the child stools. Other times the stools temporarily may get hard and stooling may be infrequent (constipation). Other times, temporarily the stools may be loose (diarrhea). Children who have FAP associated with these changes in stooling are termed as having irritable bowel syndrome. Where the belly pain is located and when it occurs can help us further categorize children (for example, functional dyspepsia). I’ll have more to say on these conditions in future blog posts.

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Our current understanding in 2012 is that there are a number of things that contribute to children having belly pain in FAP; that is, the cause is multifactorial. One particular factor may play a greater role in one child versus another <see figure>. We’ll delve more into some of these factors, how they are assessed, and how our treatments are based on these factors in future blog posts. Because FAP is so common and the pain can be so disruptive to the lives of children and their families, I along with other physicians and scientists at Baylor College of Medicine  and Texas Children’s Hospital are working hard to learn more about FAP and how best to treat it. My hope is that we will be able to develop better ways to identify which factors may be playing a role in a specific child with FAP and how best to help each child with this common problem.