Common Causes of Recurrent Abdominal Pain in Indian Children: Symptoms & Effective Treatments

Common Causes of Recurrent Abdominal Pain in Indian Children: When to See a Specialist
Recurrent abdominal pain is a common gastrointestinal issue in children, affecting about 10% of school-aged children and teenagers.

Recurrent Abdominal Pain (RAP)
Abdominal pain is one of the most common health complaints among school-aged children. Recurrent abdominal pain (RAP) is defined based on its duration and frequency, typically lasting for at least three months with a minimum of three episodes severe enough to interfere with daily activities. Many families have a child experiencing this condition. It may sometimes be accompanied by other symptoms like vomiting, irregular bowel habits, etc. 

At least one in ten school-aged children experiences this issue at some point, with diet playing a significant role in the majority. Eating less fiber often due to a lack of whole grains, fruits and fresh vegetables and instead consuming junk food mainly comprised of maida, sugary soft drinks can lead to constipation which inturn causes pain abdomen.  Fortunately, because of better hygiene and living standards, worm infestations as a cause of recurrent abdominal pain is on the decline esp. in urban areas.

Belly aches can generally be classified into two categories: the Organic group and the Non-Organic group.

Organic means there is a “definite abnormality causing inflammation, obstruction, infection, malabsorption/maldigestion, etc.” 

The non-organic group can be further divided into two sub-groups: Functional and malingering.

Functional group, here “pain is real, but there is no evident inflammation,” the cause for such pain is due to visceral hypersensitivity, gut dysbiosis, etc.

Malingering or Manchausen syndrome, which “involves a selected subset of patients who wantedly report pain to avoid school or gaining attention”

All investigations for workup of pain are normal in the non-organic group.

It is very important to differentiate organic from non-organic causes, as organic disease can be complicated if diagnosis is delayed.

A simplified way to identify organic causes of recurrent abdominal pain is to detect presence of any red flags in history or examination

It is less common compared with the non-organic group, however, it is the group which needs early identification and timely management. A referral to a pediatric gastroenterologist is warranted.

The majority are in this group. Here, the most important thing is to identify a stressor. Stressors for the child can be at home or in school. Some examples are a strict school environment, bullying, recent change of school, poor peer relationships, academic pressure, broken family etc.

The initial workup for the majority includes:

Depending on the suspicion, some of the above tests may be skipped or replaced by targeted ones

E.g., in a child with epigastric pain, stool and urine tests can be omitted, and serum amylase and serum lipase can be included.

E.g., similarly in a child with recurrent abdominal pain and loose stools with blood and mucus, urinary tests can be omitted; instead need for colonoscopy explained upfront.

The primary goal in managing children with recurrent abdominal pain (RAP) is to alleviate pain and improve their quality of life. For this, the main step lies in identifying any red flags, and if there is an organic disease, treat it accordingly.

If the recurrent abdominal pain is non-organic. Then, no time should be wasted on discussing this issue with the parents after basic initial tests are obtained. Functional Gastrointestinal pain disorder (FGID) is not a waste basket diagnosis, in fact a positive diagnosis. Treatment success for FGID’s mainly depends on identifying the stressor, dietary changes like including sufficient fiber in diet for irritable bowel syndrome, drugs like antacids, prokinteics for functional dyspepsia. Currently, role of probiotics in FGID’s is contentious as there is lack of evidence supporting its use. For FGID’s psychological counselling, cognitive behavioral therapies can be helpful. With strong reassurance and stressor management, pain can be improved significantly. 

All children with RAP having red flags needs immediate evaluation and referral to a pediatric gastroenterologist.

Red flags have been described earlier in Table 1. 

We have not discussed children with acute pain abdomen where it is always necessary to go and visit your pediatrician/pediatric gastroenterologist as it could due to serious problems like acute appendicitis, acute pancreatitis etc.

Recurrent abdominal pain (RAP) in children can be distressing, affecting not just the child but the entire family. Effectively treating the condition depends on identifying the correct diagnosis. Red flags indicate organic etiology, where timely evaluation and management is important. FGID’s constitute most of the RAP in children. Identifying stressor, dietary modifications, and reassurance can alleviate pain and improve quality of life in children with functional cause (FGID’s) of RAP.