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It is 3 a.m. and you awake with an uneasy feeling and the sound of your 3-year-old crying. “What is the matter?” you ask. “Mommy, my tummy hurts!” he responds. You try to comfort him but it is difficult to know what to do since this is not the first time this has happened. Your child has been waking up nearly five times per week for the past five weeks with the same complaint. At first you thought it might be for attention or because their were lions and tigers and bears on the wall. But now you are starting to wonder if you have let this go on a little too long. Maybe he is in pain. Maybe he is not just in dire need of attention. Maybe it really does hurt and something is really wrong! Maybe it is time to get some help. You would not be the first parent in this situation. Nearly all children will at one time or another complain of a stomachache or abdominal pain. Acute, recurrent and chronic abdominal pain often leads to emergency room visits, diagnostic testing and significant anxiety on the part of the parent and the physician. Rapid identification of a problem that requires surgical intervention is crucial to avoid complications and aggressive treatment. Even though a parent often knows when acute pain is serious, the determination of the cause may not be so easily determined. Early evaluation for acute, severe abdominal pain is the best course to take for your child. Chronic abdominal pain is defined by pain of more that two weeks duration. Complaints of chronic or recurrent abdominal pain occur in 9-17% of children and adolescents, with more than 20% having something severe enough to affect activity. A cause of the pain can be determined in more than half of the children, 25% with an organic or physical cause of the pain while about 60% were diagnosed with psychosomatic pain associated with chronic negative stress. There are certain clues that may lead you to a physical cause of the pain. The farther the pain from the belly button, the more likely is the pain to be organic. Nighttime pain that awakens your child and is associated with vomiting, weight loss, fever or blood in the stool is more likely to be associated with a physical or structural abnormality. If these symptoms occur, an evaluation by the child’s primary physician is warranted. It is best to evaluate the child in your physician’s office rather than in the emergency room or urgent care. This will give the doctor more time to get a good history and perform a detailed physical exam, avoiding unnecessary tests and anxiety. Although the specific tests ordered are determined by your child’s history and physical exam, there are a few that are more commonly performed. Stool examination: A physician will often order an examination of the stool. Your physician will be looking for blood, white blood cells that may indicate inflammation, parasites and a variety of bacteria. Newer tests for specific organisms such as Giardia and H. pylori, have increased the diagnostic ease and accuracy leading to specific treatment and cure. Signs of poor absorption and food intolerance can be in the stool leading to the diagnosis of celiac disease or protein intolerance. Blood test: Blood tests can help look for signs of chronic disease such as anemia, malnutrition and liver disease. Imbalance in electrolytes (sodium, potassium and chloride) can be present if there is chronic diarrhea. Urine: Evaluation of the urine can determine the presence (or absence) of a urinary tract infection, not an uncommon cause of chronic abdominal pain. Radiology: Although not the first test that is usually performed, abdominal ultrasound, CAT scan or upper GI may be required to evaluate the anatomy of the intestinal tract and other abdominal organs. A pain diary can be helpful to the physician when trying to determine the cause of chronic abdominal pain. Keep in mind that most children with abdominal pain do NOT have a physical cause of the chronic pain. If the pain is due to a stress-related situation, it can help if you are calm and reassuring rather than anxious and discouraging. However, if the “red flags” are present, don’t be afraid to be your child’s advocate and move toward testing more rapidly. Be open with your child and the physician. Your teamwork will be very helpful in finding the cause of the pain. Dr. Clyde Wesp is a pediatrician with Southern Orange County Pediatric Associates with offices in Lake Forest, Laguna Hills, Rancho Santa Margarita, Ladera Ranch and San Clemente (Talega) and is affiliated with Saddleback Memorial Medical Center, Mission Hospital and Children’s Hospital of Orange County. He is a member of the American Academy of Pediatrics and the Memorial Care Physician Society. If you have any questions or comments for Dr. Wesp you can email him at askdrwesp@netscape.net. |
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