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; often verbalized by kids when a parent says “Eat your vegetables” or perhaps “Clean your room”.

 

 

The list of causes of tummy aches is a long one (unfortunately for us pediatricians), but luckily the great majority are not serious. Pain associated with vomiting, diarrhea or urinary frequency is almost always due to a discrete illness which can be easily diagnosed and treated. When pain is the only symptom, diagnosis can be much more of a challenge, especially when it’s chronic.

 

Examining a child’s abdomen really only works if the child can relax the abdominal muscles. A crying infant or child has tense hard muscles which make it virtually impossible for even the most experienced doctor to detect pathology in the abdomen.

 

A ticklish child can also make the exam difficult; but fortunately, if they’re laughing, they’re probably not too terribly sick.

 

Age of the child obviously plays a part. An infant can’t verbalize his/her discomfort, but “doubling up” and crying are common signs. Common causes for abdominal discomfort in infants and toddlers are constipation, GERD, stomach or intestinal viruses (“gastroenteritis”), food intolerance (cow’s milk, wheat, etc), and urinary tract infections (“UTI’s). Colic is often thought to reflect abdominal pain, but who really knows?

 

School-age kids often present with what doctors call “functional” abdominal pain. This is when there are no obvious physical or organic causes, and the pain is presumably due to stress or psychological causes. One example is where a child just starting school refuses to go, complaining of a tummy ache. This is due to separation anxiety or so called “school phobia”. The same thing may happen with an older child who’s being bullied and is trying to avoid school.

 

Another somewhat related entity seen in kids age 8 – 12 is “chronic abdominal pain of childhood”. This is what pediatricians call it when the history, physical exam and diagnostic testing show no apparent reason for the pain. These kids are often high functioning, straight-A students who put a lot of pressure on themselves. Sometimes they are over-scheduled with activities outside school. Maybe the abdominal pain is their body’s way of forcing them to slow down. When asked about stress, they almost uniformly deny it. If asked to point to where the pain is, they usually point to the navel. Thus the pediatric rule of thumb “The closer the pain is to the belly-button, the less likely you’ll ever find a cause for it”. However, some recent research indicated that up to 50% of kids with chronic abdominal pain may have fructose intolerance. Further studies will have to be done to confirm this. A trial low-fructose diet for 2-4 weeks may be worth a try.

 

Another pain entity in older kids which is probably under-diagnosed is “abdominal migraine”. This pain is often associated with pallor (a pale appearance), nausea, vomiting, and headache, and can be disabling. A family history of migraine headaches is common. The child often has a history of car sickness. Pain associated with vomiting, diarrhea, burning with urination, frequent urination of large amounts, or weight loss is much more likely to have an organic cause and should be evaluated.

 

Infections, either viral or bacterial may cause abdominal pain, almost always accompanied by vomiting and/or diarrhea. Pain is more likely with bacterial infection (salmonella, shigella, etc). Parasites like giardia or amoeba may cause tummy discomfort like nausea or queasiness, less commonly pain. So called “food-poisoning” is caused by eating food contaminated with toxin-producing bacteria.

 

Pain following abdominal trauma may indicate injury to an internal organ (liver, spleen, or kidney). Prompt evaluation is important.

 

Adolescent females often get abdominal cramping either mid-cycle or pre-menstrually. Twisted ovarian cysts, testicular torsion (twisting), and hernias are also on the list, but further down (no pun intended). Inflammatory bowel diseases (“IBD”) like Crohns disease or ulcerative colitis cause chronic intermittent symptoms. Celiac disease (gluten enteropathy) can be tricky to diagnose (which doesn’t seem to deter many lay people from diagnosing themselves with it).

 

The classic “surgical abdomen” is when the abdomen is rigid and extremely tender to palpation. Appendicitis and other surgical problems where intestine kinks on itself causing a blockage or obstruction are quite uncommon compared to other causes of abdominal pain. The child will be quite ill-appearing with repeated vomiting and severe pain. Appropriate evaluation and intervention is essential. Appendicitis is very unusual in infants and toddlers.

 

Everyone can relate to having a tummy ache as a child; it may have been something as obvious as eating too much Halloween candy; or in my case, too many mustard sandwiches (I loved mustard!). Luckily, the cause is usually something benign and the pain is self-limited.

 

Happy New Year!

 

 

Healthy Kidz Doc is written by a board-certified pediatrician who's practiced in Santa Cruz County since 1986. www.healthykidzdoc.yourmd.com

 

 
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