Chronic or recurrent abdominal pain in children

First: screen for red flags

• Weight loss, poor weight gain, slowed height growth, or delayed puberty
• Blood in vomit or stool, black stools, anemia
• Persistent or bilious vomiting
• Chronic severe or nocturnal diarrhea
• Fever, jaundice, joint swelling, rash, mouth ulcers
• Persistent localized right-upper or right-lower abdominal pain
• Nocturnal pain that wakes the child repeatedly
• Palpable mass, hepatosplenomegaly, focal guarding, or abnormal perianal examination
• Family history of inflammatory bowel disease, celiac disease, or peptic ulcer disease
• Urinary symptoms, menstrual/pelvic symptoms in adolescents, or concern for pregnancy
• Acute severe worsening, abdominal distension, dehydration, or inability to walk/jump because of pain

Common causes

• Irritable bowel syndrome: pain related to defecation and altered stool frequency or form
• Functional dyspepsia: upper abdominal discomfort, early fullness, nausea
• Abdominal migraine: discrete episodes of intense midline/periumbilical pain with pallor, nausea, vomiting, or migraine history
• Functional abdominal pain, not otherwise specified

• Celiac disease
• Inflammatory bowel disease
• Gastroesophageal reflux or peptic disease in selected cases
• Lactose or other carbohydrate intolerance
• Urinary tract disease, nephrolithiasis
• Parasitic or other infection where exposure supports it
• Gynecologic causes in adolescents
• Less often: biliary, pancreatic, metabolic, anatomic, or neurologic disorders

Practical evaluation

• Site, timing, duration, severity, triggers, relation to meals and stooling
• Stool pattern, vomiting, appetite, urinary symptoms, sleep, school attendance, stressors, and functional impact
• Diet and medication history, including NSAID use
• Growth chart and complete abdominal, perianal, skin, joint, and pubertal examination

Management when functional pain is likely

1. Explain that the pain is real and common, while reassuring the family that serious disease is unlikely after an appropriate evaluation.
2. Set functional goals: regular school attendance, sleep, meals, physical activity, and social activities, rather than waiting for pain to be zero.
3. Treat constipation if present.
4. Encourage regular meals, hydration, adequate fiber when appropriate, activity, and sleep routine. Avoid overly restrictive diets unless there is a clear, supervised indication.
5. Use psychological therapies when pain affects function. CBT and gut-directed hypnotherapy have the best evidence among non-drug options. A 2024 meta-analysis of 10 trials involving 1,187 children found CBT improved disability, pain intensity, and quality of life versus usual care, though effect estimates varied across studies (Huang et al., 2024).
6. Refer to pediatric gastroenterology when there are alarm features, abnormal screening tests, poor growth, diagnostic uncertainty, or disabling symptoms despite primary care management.