The Approach to the Management of a Child with Chronic Abdominal Pain

Abstract

Purpose of Review Abdominal pain occurs frequently in children; chronic abdominal pain affects about 15% of children. There is always an initial concern for serious organic medical conditions; these can be eliminated with careful history and physical examination, especially looking for “red flags.” These children are often subjected to numerous invasive and noninvasive tests; excessive testing should be avoided. There is no evidence extensive testing improves patient outcome or satisfaction. Recent guidelines recommend celiac serology and fecal calprotectin/lactoferrin as the optimal screening tests. Anxiety is often a co-morbidity; the continued testing and lack of explanation exacerbate the symptoms and cause more dysfunction. Recent Findings Ongoing research suggests chronic abdominal pain is a complex interaction of genetics, environmental factors including diet, changes in the microbiome, previous life events, and stresses. The gut-brain axis is now more accurately described as the microbiome-gut-brain axis. Many disturbances have been reported but it remains unclear which are causative versus reactive. Therapeutic interventions have targeted one or more of the components but rarely in a coordinated manner. A positive diagnosis and explanation of pathophysiology are crucial first steps. A holistic approach that focuses on restoration of functioning and well-being is the best approach. A non-pharmacologic approach is the favored initial therapy; many children improve with counseling and assurance that there are no serious organic disorders. A trusting relationship with child and family is an integral part of the treatment plan. Summary Pediatric chronic abdominal pain is commonly encountered in practice. Serious conditions can be eliminated by determining whether any of the so-called red flags are present and judicious testing. High quality evidence is lacking for many proposed treatments. Data interpretation is confounded by a high placebo response rate, even when the placebo is unblinded. The current best evidence is for non-pharmacologic treatments including cognitive behavioral therapy and hypnosis. Neuromodulation is a new, promising intervention.