Abdominal pain in children
‘I have a headache in my stomach’
Recurrent abdominal pain in kids is an issue in clinic I see more frequently than ever, and I am not surprised with between 4% to 25% of school-aged children experiencing severe enough abdominal pain to interfere with their daily activities. The title of this article refers to a story my dad told me, which was that when he was young, under 5 years old, he had severe tummy pain but didn’t know how to explain how he was feeling to his mother, so came up with his best guess estimate, ‘a headache in my stomach’. And in fact, he may not have been far wrong; abdominal pain can be commonly associated with other symptoms, including headaches, recurrent limb pains, pallor, and vomiting. I have also observed it can be associated with anxiety, both for the child but also their parents, driven by an inability to help relieve suffering and a fear of more serious disease.
The frustrating thing about abdominal pain, and functional gastrointestinal disorders in general, is that they frequently have an unclear cause. They are functional (disorders of gut-brain interaction), rather than pathological (caused by disease). However, there is a growing consensus that there is a strong relationship with a number factors such as:
visceral hypersensitivity (pain or discomfort in organs, in this case the stomach, small or large bowel)
disturbances with motility, which relates to changes with the movement of food through the stomach, small and large intestine and out of the body,
changes in mucosal function (the innermost layers of the gut)
changes in the gut immunity (immune cells in the gut that interact with the gut microbiota)
alterations of the gut microbiota (gut bugs) often leading to a more pro- rather than anti-inflammatory gut environment and
changes in the gut brain axis, which alters how the central nervous system receives and processes information coming from the gut.
Unfortunately, from a medical perspective, there is no clear consensus about how to manage abdominal pain in children, leading to inconsistent and often unhelpful treatment. This is not surprising. A recent high level summary review was completed by researchers to establish current evidence in order to direct treatment decisions. The results were interesting but varied, and in my opinion indicate that an individualised assessment and treatment approach needs to be applied for each patient. See the overview of research below. I have excluded reports about pharmaceutical approaches as overall there was insufficient evidence to recommend them at all.
Probiotics – can help improve pain but there is no consensus about the specific strain and various were used across 8 trials, although Lactobacillus rhamnoses GG and VSL#3 are more likely to show benefit.
Pooled results of 4 studies looking at different high fibre diets in IBS were not consistent and varied outcomes may be due to the suitability of fibre in different types of IBS (my comment).
FODMAP diet – only one small study looked at this dietary intervention in children, and another at fructose reduction. While there was a reduction in pain intensity and frequency, I am very cautious about the use of diets that restrict significant food groups and minimise diversity in growing bodies. A selective approach can often yield similar outcomes and taking a good diet history man help to narrow down dietary elimination in children.
Cognitive behavioural therapy – improved pain immediately post intervention with a number needed to treat (NNTB) of 4, which means that four children would need to receive CBT for one to experience improvements in pain.
Hypnotherapy – improvement in pain was also seen immediately after the intervention with a NNTB of 3. Longer term (5 years later) up to 68% of children were still symptom free compared to 20% of a control arm. Both pain intensity and frequency remained lower after 3 months of hypnotherapy.
Yoga and written self-reflection – of the 2 studies available, neither intervention found evidence of an effect on pain.
The findings of this review show some treatment directions are more likely to have a positive benefit than others. The nature of abdominal pain is that it can fluctuate in its presentation so on the surface it can seem that there is no consistent therapeutic approach, particularly when the approaches are not individualised to the child. The authors of the paper suggest there may be distinct clinical sub-types of recurrent abdominal pain, which I tend to agree with and certainly, in my clinic no child presents the same and often, no treatment approach is the same. In this context, I think that a treatment approach following evidence guidelines should always be considered but more importantly, needs to be based on the individual presentation of the child, and certainly this is the approach I take.
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Article reference:
Abbott, R. A., Martin, A. E., Newlove-Delgado, T. V., Bethel, A., Whear, R. S., Coon, J. T., & Logan, S. (2018). Recurrent abdominal pain in children: summary evidence from 3 systematic reviews of treatment effectiveness. Journal of pediatric gastroenterology and nutrition, 67(1), 23-33.