Functional Abdominal Pain in Children

Background

• Functional abdominal pain is defined as episodic (≥ 1 episode per week) or continuous abdominal pain for ≥ 2 months which cannot be explained by structural or biochemical abnormalities.
• This is a common problem in children worldwide, likely multifactorial in nature, related to biopsychosocial factors and potentially altered visceral sensation, hormonal changes, inflammation, and disturbances in gastrointestinal motility or bowel microbiota.
• Psychological factors such as abuse, stressful life events, and depression are likely to contribute to functional abdominal pain in children. Having a parent with anxiety or a functional gastrointestinal disorder may also increase the likelihood of functional abdominal pain in children.

Evaluation

• A clinical diagnosis of functional abdominal pain is sufficient and encouraged for patients aged 4-18 years based on comprehensive history and physical exam findings of episodic or continuous abdominal pain for 2 months and the absence of alarm symptoms or signs that may suggest an organic cause.
• Fecal occult blood testing is the only test recommended by the American Academy of Pediatrics, although additional testing is sometimes pursued to reassure the patient, parent, or physician, especially if pain significantly affects quality of life.
• Other testing to rule out organic causes may include:
  • complete blood count and C-reactive protein levels
  • celiac disease screening
  • stool analysis for Giardia lamblia infection and fecal calprotectin levels
• Imaging studies or other diagnostic tests may be considered but are often not necessary.

Management

• The goals of treatment include the resumption of a normal lifestyle with regular school attendance, a normal sleep pattern, and participation in extracurricular activities, but may not always include the complete eradication of pain.
• A multidisciplinary approach may be necessary in children with associated social and psychological conditions.
• Providers should explain the diagnosis of functional abdominal pain to the parents and child and provide reassurance that symptoms are real but rarely associated with an underlying serious or chronic disease.
• Placebo has been demonstrated to have a strong response in children with abdominal pain-predominant functional gastrointestinal disorders, up to 50% in some trials.
• Consider a judicious time-limited use of medications in individual cases to help decrease the frequency or severity of symptoms.
  • Acid-reduction therapy may improve pain associated with dyspepsia.
  • Antispasmodic agents, smooth muscle relaxants, or low doses of psychotropic agents may improve abdominal pain.
  • Nonstimulating laxatives or antidiarrheals may offer relief for pain associated with an altered bowel pattern.
  • Other medications that may be considered include antidepressants and antihistamine agents.
  • Consider probiotics, especially in patients with symptoms of irritable bowel syndrome.
• Consider psychosocial interventions such as cognitive behavioral therapy and hypnotherapy.
• Dietary modifications may be considered but there is limited evidence on the efficacy of elimination diets and increased dietary fiber intake.