Scenarios of How to Identify Abdominal Pain
Your 5 year old has occasional bouts of severe abdominal pain- It usually only last for a few hours, but now it’s been happening more frequently and she is asking to go to the doctor.
For the past four months your 9 year old has been complaining of a stomachache almost daily- It hasn’t really slowed him down, and it seems fairly mild.
Your 18 month old keeps pointing to her tummy and saying “ow-eeee”- This has been happening on and off for several months now and you’re starting to get concerned.
These are all very common situations many parents face, and for most kids, the pain is mild and temporary. Many parents may also think their older child is faking or exaggerating the symptoms, especially when doctors don't seem too concerned. However, dealing with long-term stomach aches means these abdominal pains could be more serious than they appear. Chronic abdominal pain is a very common condition, but unfortunately it is often very difficult to find the cause. Here are some guidelines to help you understand what may be causing the pain, how you can investigate it, and what symptoms need medical attention.
If the pain is not serious, but goes on for several days, you should probably have your pediatrician check it out during office hours.
Important note - this discussion focuses on sudden causes of pain, such as the scenarios listed above.
Top 4 causes of non-serious abdominal pain
In newborns and younger infants:
- Colic – this refers to episodes of inconsolable crying for hours. The baby seems to be crying in pain, and the source of the pain appears to be the abdominal area. This is a very complex issue. See our article on Colic for more information.
- Stomach upset from something in the mother's diet in breastfeeding infants. For a list of foods that can cause this, see our article on Colic-causing foods.
- Formula intolerance – Read more about finding the right formula if your baby isn't tolerating one.
- Gas – this is by far the most common cause. Almost every baby goes through fussy, gassy periods. It is often from an irritating food in mom's diet, a formula intolerance, swallowed air during excessive crying, or from inadequate burping after feeds.
Non-Serious Abdominal Pain
Top 7 causes of non-serious abdominal pain
Older infants and children:
These causes are not serious and usually don't require a call to your doctor or any other urgent medical intervention:
- Intestinal illness – the most common cause of abdominal pain is the stomach or intestinal flu. If your child has vomiting, diarrhea, and fever, then you can be fairly sure the stomach pain is simply a part of a non-treatable and non-serious infection. Click on Vomiting, Diarrhea or Fever for help with these specific symptoms. Hepatitis A is another viral infection that can cause sudden belly pain, usually the right, upper belly where the liver is. Children will usually turn yellow during this infection. This is relatively rare, and occurs in outbreaks from restaurants or schools. Don't worry that you child may have hepatitis during a fever and vomiting illness because it is almost always a stomach flu, not actual hepatitis.
- Food poisoning – this isn't really "poisoning" as the term implies. It simply means there were some bad bacteria in something your child ate. If your child has sudden abdominal cramps, vomiting, and possibly diarrhea within 1 to 8 hours after eating some suspicious food, then it is probably food poisoning. Click here on Vomiting for help with this. Common foods that cause this include: fish, beef and mayonnaise.
- Gas – this is probably the most common cause of abdominal pain in the absence of any vomiting and diarrhea illness. Your child will experience sharp pains on and off that may move throughout the abdomen. Older children may tell you they can feel the gas bubbles moving along.
- Upset stomach or heartburn – this is different from food poisoning or gas pain. This simply means that your child ate something that didn't agree with him, or has a temporary over-production of stomach acid. The pain is usually over the stomach (the upper middle and left side of the belly below the ribcage) or in the chest and may be described as burning or gnawing. Categories of offending foods include:
- Food intolerance or allergy – most commonly dairy products, nuts, berries, fish, wheat, eggs. Consider this if your child ate something for the first or second time.
- Acidic foods – foods that may cause heartburn include: foods with tomato sauce, greasy foods, and citrus fruits or juices.
- Almost any food may cause heartburn or upset stomach in some kids. Keep track of these suspected foods.
- Sore abdominal muscles – if your child has recently participated in an active sport or activity involving use of the abdominal muscles, this can create extreme soreness of these muscles. The pain is worse when you push on the belly or when your child uses the muscles such as in sitting up. These muscles may also become sore after prolonged vomiting.
- Menstrual cramps – don't forget this cause in teenage girls. Cramps can occur even before periods have started. These are usually fairly obvious – cramping lower abdominal pain, may include back pain. It can start as young as 9 or 10 years of age. Treatment is ibuprofen click here for dosing. Please note that Ibuprofen can cause stomach upset.
- Constipation – this is more often a cause of chronic abdominal pain. However, your child may have sudden onset of constipation that can cause severe abdominal pain. The pain can occur anywhere in the belly, although it is most often right in the middle near the belly button. The pain will come and go as the colon naturally contracts, trying to move the hard stool along. Click on Constipation for more help with this.
6 ways to sooth abdominal pain
If you have determined that your child is experiencing one of the non-serious causes of pain, here are some tips on how to relieve the discomfort:
- Intestinal illnesses, food poisoning or sore abdominal muscles – sit your child in a warm bath, gently rub his tummy, place warm towels or hot water bottle over his tummy. Try Ben-gay or similar cream for sore muscles.
- Gas pain – massage the tummy to try to move the gas bubbles along. You can give your child (even your newborn) some simethicone drops (Mylicon is a brand name). A warm bath may also help.
- Upset stomach or heartburn – give your child an antacid. Mylanta or Maalox work well. Tums is another choice. A drink of milk can also sooth heartburn.
- Constipation – click on it for more information.
- Menstrual cramps – ibuprofen, ibuprofen, ibuprofen! Ask your wife, it's probably her best friend!
- Colic – click on it for more information.
Chronic Abdominal Pain
Important note – this section deals with chronic, long-term abdominal pain.
Top 5 most common causes of chronic abdominal pain
This is by far the most common cause of chronic abdominal pain. Here are some clues to help you decide if this is the cause:
- Occurs several times a day - as the colon contracts several times a day against the hard backed-up stool, your child will complain of cramping pain. Pain will subside after contraction stops, usually after 10 to 30 minutes.
- Child often points to the belly button as the site of pain.
- Pain varies from mild to severe.
- Your child may have symptoms such as:
- Straining hard to pass a bowel movement
- Thick, hard stools
- Having a bowel movement only once every few days
- Some children can have abdominal pain from constipation but not have any other obvious signs of constipation. Some less obvious clues to possible constipation include:
- Infrequent bowel movements
- Taking a long time to pass a stool, spending 10 minutes or more on the toilet
- When your child does go, they pass a lot of stool
- Passing small, hard grape-sized pieces frequently
- Small stool marks soil their underwear
If you think constipation may be a cause of your child's abdominal pain, click on Constipation for an in-depth discussion on this topic.
2. Lactose intolerance or milk protein allergy
These two conditions are actually not the same thing. One is an inability to digest lactose sugar, while the other is an allergic reaction throughout the body to milk proteins. Both, however, can cause upset stomach and abdominal pain. Symptoms include:
- Stomach cramps after eating dairy
- Gas pains
- Intestinal cramps
- The pain is usually a cramped, gassy pain felt anywhere in the abdomen. Naturally, it often is worse after eating dairy, but may come and go anytime during the day.
3. Heartburn, gastritis and ulcers
Gastritis is the medical term for upset stomach or heartburn. It refers to inflammation in the stomach caused by over-production of stomach acid. Ulcers occur when this acid erodes too far into the stomach lining. Older children will describe it as a burning or gnawing pain over the upper middle or left side of the abdomen, or even the middle of the chest. Unfortunately, younger children have a hard time describing a pain as "burning." So there are three main causes of this over-production of acid to be aware of:
- Stress – emotional stress in children can cause increased stomach acid and stomach aches.
- Infection – there is a particular bacteria called Helicobacter Pylori that can infect the stomach and cause increased stomach acid and pain. This infection can be hereditary. It is diagnosed either by a simple blood test or with a biopsy taken during an endoscopy of the stomach, however, this blood test is not very reliable for children under 5 years old.
- Medications – some medications can cause stomach irritation. The most common culprits are aspirin and ibuprofen products.
The treatment for gastritis or stomach ulcers is to take antacid pills before meals (Zantac 75 or Pepcid AC are two common over-the-counter ones) or after meals you can try Tums, Maalox or Mylanta. If this type of burning pain continues for more than two weeks, you should see your doctor.
4. Intestinal infections
There are a variety of bacteria and parasites that can infect the stomach or intestines. The pain can occur anywhere in the belly. The biggest clue that the abdominal pain may be due to an intestinal infection is the presence of chronic diarrhea. These infections are diagnosed by sending samples of the diarrhea to a lab for testing. The treatment is medication to eradicate the infection.
5. Behavioral causes of abdominal pain
This is particularly common in children ages 4 to 7 years old. They will complain of belly pain simply to get more attention. The pain is probably not real in this case, however, if your child's desire for attention is very strong, she may perceive the pain as real. This commonly occurs when a new baby arrives in the family, causing your older child to feel left out. It can also occur during a move, when starting a new school, a family tragedy, or any other time when your child may feel left out, insecure or worried about something. One way to approach this situation is to simply acknowledge your child by saying something like "I know dear, sometimes my tummy hurts too. But you will be okay." Don't give any special attention to it, and do not try to help your child find a remedy. For example, do not have them lay down and you rub their tummy to make it feel better. Instead, make an effort to give your child extra attention at times when the are NOT complaining. This will lessen your child's need to complain for attention. However, there is really no way to know for sure if the pain is due to behavior or illness, so use your parental instinct, and do not ignore the pain longer that you feel is appropriate.
Other causes of chronic abdominal pain
There are many other, less common causes which include:
- Tumors – this is an extremely rare occurrence in children. The doctor can often feel an abdominal mass. Do not jump to this as a possible diagnosis, because it is extremely rare.
- Organ problems – again, very rarely, one of the abdominal organs may have a problem. These include the liver, gallbladder, pancreas, kidneys, and spleen.
Evaluating abdominal pain
When to see the doctor
If the pain is mild and not interfering with your child's life or sleep, then it is okay to observe your child for a few weeks. The pain usually goes away on its own. If the pain is moderate to severe, then see your doctor.
Develop a pain diary
Your doctor will need to know many details regarding the pain in order to evaluate its cause. Keep a diary for several weeks. Write down every day when the pain occurs, and answer the following questions with each episode:
- Time of day
- Before, after, or nowhere near a meal
- Severity on a scale of 1 to 10 – does your child simply tell you their tummy hurts, but shows no outward signs? Or do they double over in pain, holding their stomach and rolling on the floor?
- How long each episode lasts
- Where in the belly is the pain
- What do you do to help the pain – what remedies have worked, what has not worked.
- What is your child doing right before the pain occurs
- Does it awaken your child at night
- Does it occur only at school, or only at home, or both
- Does it occur on the weekends
The answers to these questions will be very valuable to your doctor, so come to your appointment well prepared.
Medical tests to find the cause of abdominal pain
You and your doctor will first decide if and when any testing is warranted. After talking to you, examining your child, and reviewing your pain diary, many times the doctor can diagnose the cause without any testing. If tests are necessary to determine the cause, here is a typical protocol that your doctor may follow. These tests go in order of least expensive, most helpful and most convenient, to most expensive, least helpful and least convenient:
- X-ray: This may sound extreme as the first test to do, but one simple X-ray can be very helpful, easy to do, and fairly inexpensive. It can diagnose such things as tumors, constipation, swallowed objects, gallstones, and kidney stones.
- Urine Tests: One important hidden cause of abdominal pain you don't want to miss is a kidney problem, so your doctor will always check your child's urine.
- Stool tests: Here are the various stool tests your doctor may order. They require you to pick up a special sterile container from the lab first. Ask the lab for any special instructions on collecting or storing the specimen before you bring it in:
- Routine culture: This will look for a variety of intestinal bacterial infections such as Salmonella and E-coli.
- Ova and Parasites (O and P): The lab will look for a variety of parasites in the stool sample.
- Rotavirus antigen: This will detect the most common cause of diarrhea infection in infants and young children. Usually your doctor can diagnose this infection without needing this test.
- Giardia antigen: This is a parasite and a fairly common cause of abdominal pain and diarrhea. It won't be found on O and P test.
- Hemocult test: This checks for hidden blood in the diarrhea, which can help your doctor determine the cause.
- Abdominal ultrasound: This is a non-invasive test (just like a pre-natal ultrasound) that examines each specific organ in the abdomen for certain problems as well as abdominal tumors.
- Blood Tests: This checks for H.pylori stomach infection. It can also check to make sure each abdominal organ is working as it should or tell if they are being damaged by an illness.
When to worry about abdominal pain
Use the guidelines above to help you decide when a doctor's appointment is necessary. It is not necessary to urgently page your doctor at night or over the weekend for chronic abdominal pain that has been occurring for several weeks. Wait until the next business day and call for an appointment.
Dr. Sears, or Dr. Bill as his “little patients” call him, has been advising busy parents on how to raise healthier families for over 40 years. He received his medical training at Harvard Medical School’s Children’s Hospital in Boston and The Hospital for Sick Children in Toronto, the world’s largest children’s hospital, where he was associate ward chief of the newborn intensive care unit before serving as the chief of pediatrics at Toronto Western Hospital, a teaching hospital of the University of Toronto. He has served as a professor of pediatrics at the University of Toronto, University of South Carolina, University of Southern California School of Medicine, and University of California: Irvine. As a father of 8 children, he coached Little League sports for 20 years, and together with his wife Martha has written more than 40 best-selling books and countless articles on nutrition, parenting, and healthy aging. He serves as a health consultant for magazines, TV, radio and other media, and his AskDrSears.com website is one of the most popular health and parenting sites. Dr. Sears has appeared on over 100 television programs, including 20/20, Good Morning America, Oprah, Today, The View, and Dr. Phil, and was featured on the cover of TIME Magazine in May 2012. He is noted for his science-made-simple-and-fun approach to family health.