Recurring Abdominal Pain
Recurring abdominal pain is abdominal pain that occurs 3 or more times over a period of at least 3 months.
About 1 in 10 school-aged children has recurring abdominal pain. It is most common in children between the ages of 8 and 10 and is rare in those younger than 4. Recurring abdominal pain is slightly more common among girls than boys and is fairly common among girls in early adolescence.
Causes
In most children, recurring abdominal pain is caused by anxiety and other psychologic distress that is a result of stress at school, with friends, between parents, or within a family. A significant number of children with the condition are depressed. About 1 in 10 have an identifiable physical cause, usually from a digestive or genitourinary tract disorder. The absence of a physical cause in most children is sometimes frustrating for parents.
When recurring abdominal pain has no physical cause, concerned responses from parents and teachers can make the pain better or worse to the extent that it favorably alters stressful situations to which the child is responding. For example, pain that distracts family members from arguing, garners attention for the child, or takes the child away from school or other stressful settings may be an effective way for a child to relieve anxieties he could otherwise not control. Importantly, most children do not intentionally use their symptoms to communicate distress to their parents or teachers. Rather, it is a symptom of true and significant emotional discomfort.
The most serious cause of recurring abdominal pain is sexual abuse. However, routine stresses at school or home are far more common causes of recurring abdominal pain than is sexual abuse.
 See the sidebar Some Physical Causes of Recurring Abdominal Pain.
Symptoms
Recurring abdominal pain caused by a physical condition generally recurs at predictable times or in the same location. It may be brought on by certain activities or foods and may worsen over days to months. Often, although not always, the pain may awaken the child from sleep. The child may also have other symptoms, such as loss of appetite, weight loss, changes in the form and color of bowel movements, constipation or diarrhea, vomiting of food or blood, swelling of the abdomen, recurring or persistent fever, jaundice, blood in the stools, or discomfort with urination.
Recurring abdominal pain without a clear physical cause is generally less likely to recur at predictable times and in the same location. It is often described in vague terms and occasionally disappears for weeks or months. It seldom disturbs a child during sleep but may wake him up early. The child can often be distracted from the pain by activities he enjoys; this is less likely to be the case when there are physical causes of the pain.
Diagnosis
The doctor asks the parent and child a series of questions about the character of the pain and about any symptoms that occur with it. The doctor also performs a physical examination, including a rectal examination, looking for clues for a physical cause. The interview and examination give the doctor the information to decide what additional tests, if any, the child should undergo. Often, the doctor may strongly suspect a psychologic cause just from the child's answers to questions and from observing the child and parents in the interview.
Some possible tests for recurring abdominal pain range from urine and blood tests, which can detect infection, to more invasive procedures, such as colonoscopy, which can detect inflammation and other abnormalities within the large intestine. However, invasive tests are rarely needed. Given the frequency with which depression or anxiety accompanies symptoms of recurring abdominal pain, many doctors consider psychologic assessment to be the most important test.
Treatment
Physical causes of recurring abdominal pain are treated for the specific disorder responsible. When a physical cause for the child's symptoms cannot be found, a doctor may suspect a psychologic cause. Treatment then depends on good communication and a trusting relationship with the doctor as well as periodic monitoring of the child's symptoms.
The child should be supported in efforts to return to a full range of activities, including school. Teachers have a large role to play in limiting the child's withdrawal from activities with peers and in helping the child resolve conflicts related to school. A child who needs to leave class because of pain should be allowed to visit the school nurse for only a limited time. With the parents' permission, the nurse can give the child a mild pain reliever, such as ibuprofen or acetaminophen, if necessary. Typically, a child will request time in the nurse's office 1 or more times a day during the first week or two of treatment. Over time, the behavior becomes less frequent. Generally, when the parents stop treating the child as different or ill, pain with a psychologic cause initially worsens but then improves.
A child whose abdominal pain has no physical cause may be helped by seeing the doctor at regular intervals--weekly, monthly, or every other month--depending on the child's needs. In some cases, the doctor may prescribe antidepressants or antianxiety drugs. This treatment may result in a reduction or disappearance of the child's symptoms, but it is not always successful. Some children may develop new physical symptoms or emotional difficulties, or they may express unresolved emotional difficulties with new symptoms, such as a headache. If the pain persists despite all efforts, especially if the child is severely depressed or if there are significant psychologic problems at home, the child may need to see a mental health professional.
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