Functional Abdominal Pain in Children: A Q&A With Dr. Nicole Pattamanuch, Plus a New Algorithm for Providers
June 7, 2023
More than 100 new patients are referred to Seattle Children’s GI program each month for functional abdominal pain, with an average wait time to be seen of typically 3 to 5 months. To help PCPs manage these patients longer in primary care so they can get care sooner and identify situations and red flags that indicate specialty care is needed, our GI doctors developed an algorithm for chronic abdominal pain that is now available on our website at seattlechildrens.org/algorithms.
We spoke with Dr. Nicole Pattamanuch, director of our General GI program, to learn more about caring for kids with functional abdominal pain.
Q: What are the most common causes of functional abdominal pain, by age group?
Functional abdominal pain is one of the most common complaints we see in GI. The exact cause isn’t known; usually it’s multifactorial. We know emotional distress plays a role, by exacerbating gut/brain axis disorders and making it more difficult for a child or teen to cope with the pain signals their body is sending.
We tend to see functional abdominal pain in school-age children and adolescents. For younger, preschool-age children who are reporting belly pain, I’d be less suspicious of functional abdominal pain and instead consider a more serious pathology.
For a quick introduction to the gut-brain interaction, two articles I recommend are:
- Recognizing and treating disorders of gut-brain interaction, by Christopher Velez, MD (Harvard Health Publishing, 4-20-22)
- Disorders of gut-brain interaction in pediatrics: a few observations, by Sam Nurko (Rome Foundation)
Q: What are the red flags for functional abdominal pain?
The red flags we look for are:
- A concerning physical exam, meaning the child reports pain when their belly is touched or palpated (most kids with functional abdominal pain will not report pain on exam)
- Chronic (persistent in intensity AND lasting longer than 14 days) diarrhea
- Chronic vomiting
- Blood in the stool
- Pain that impairs the patient’s ability to eat AND translates into severe malnutrition OR weight loss
- Pain that’s associated with multisystem inflammation, which includes joint pain, rash pain and oral ulcers
A red flag doesn’t necessarily mean the situation is urgent but signals that a referral to GI is warranted.
Q: When should I refer to GI? When is it routine versus urgent?
Refer your patient to GI when you see red flags for functional abdominal pain (above), even if the labs are normal. If the patient has significant symptoms plus lab abnormalities and/or severe or acute weight loss, please mark the referral as urgent.
Q: What workup do you recommend when referring a patient for functional abdominal pain?
We recommend labs for CBC, ESR/CRP, albumin, TTG IgA, total IgA, TSH, stool H. pylori, stool Giardia/crypto and stool calprotectin. The stool tests are helpful in that they give us more data while being a very benign test for the patient. Stool tests also can help us give additional reassurance to the family.
Q: When should primary care providers order diagnostics or consider advanced imaging, including endoscopy (or not do these things)?
By type of test:
- Ultrasound: I encourage ordering an ultrasound only if there’s a specific question the provider is trying to answer. For example, if there’s a mass you’ve palpated on exam, or focal tenderness, or concern for gallstones or kidney stones. Although it can be tempting to order an ultrasound to give families peace of mind, absent of a clear need, the results usually are normal and not helpful.
- CT scans also should only be done when there’s a focused question, like a concern for appendicitis or if there are acute surgical abdominal problems such as obstruction or perforation. CT scans tend to be more useful in situations where you’re able to palpate to elicit pain on exam.
- X-rays: I discourage ordering x-rays for assessing and diagnosing constipation. Physical exam and clinical history alone should be enough to accomplish that. An exception could be use of x-ray for assessing for fecal impaction in the setting of fecal incontinence, which x-ray can be useful for. Barring that, we do not recommend x-rays as part of the workup prior to referral to GI.
Q: When is endoscopy appropriate for diagnosing functional abdominal pain?
We can make a functional abdominal pain diagnosis with just a patient’s history, labs and physical exam. Upper endoscopy is an appropriate diagnostic tool only for specific situations:
- Chronic vomiting
- Chronic diarrhea not explained by infection or dietary triggers AND associated with other red flag symptoms
- Blood in emesis or stool
- GI symptoms associated with significant lab abnormalities and/or weight loss
- Abnormal celiac serology
- Polyposis syndrome
Q: How is functional abdominal pain diagnosed, and how does it vary by age?
I recommend the updated Rome IV criteria found here in section H2d. The criteria must be fulfilled for at least two months before diagnosis, must be met at least four times per month, and must include all of the following:
- Episodic or continuous abdominal pain that does not occur solely during physiological events such as eating and menses.
- Insufficient criteria for other functional GI disorders, including irritable bowel syndrome, functional dyspepsia or abdominal migraine.
- After appropriate evaluation, the abdominal pain cannot be fully explained by another medical condition.
Q: What are the evidence-based approaches to treatment for functional abdominal pain?
Proven therapies to reduce symptoms of functional abdominal pain include those that focus on the brain-gut connection, such as hypnotherapy, cognitive behavioral therapy (CBT) and biofeedback. These treatments are available in the community. Many patients benefit from behavioral support for anxiety and/or depression.
In terms of medication, daily supplements of peppermint oil capsules and the herbal supplement IBgard both offer relief. Peppermint is often not tolerated well by kids due to reflux from the extreme mintiness; IBgard is better tolerated. Both have been studied in adults and kids with functional abdominal pain. Antispasmodics, including dicyclomine and hyoscyamine, can be helpful with cramping pain and are safe for pediatric use.
Q: Do you have suggestions for talking to patients and families about functional abdominal pain?
The most important thing is to validate the realness of the child’s pain and let families and patients know that functional abdominal pain is very common in children and teens. It’s helpful to offer reassurance that their child’s growth or general good health won’t be affected and that functional abdominal pain isn’t dangerous. Please see our patient handout Functional Abdominal Pain: How to Help With Your Child’s Chronic Abdominal Pain (Spanish).
When referring your patient to Seattle Children’s GI for further evaluation, we recommend caution in advising the family on diagnostic tests that will be offered by a specialist. Families that come to us expecting endoscopy, for example, often feel disappointed if we don’t recommend it, and we lose valuable time during their child’s appointment educating them about why it’s not recommended.
You can recommend therapies the child can get started on (see above – CBD, hypnotherapy, biofeedback, peppermint oil, etc.). Some resources we like are:
- The WA Mental Health Referral Service for Children and Teens – a free telephone service that matches families with therapists for their child who take their insurance and have immediate availability. They are able to look for biofeedback therapists specifically, as well as BIPOC therapists, upon request.
- Seattle Children’s kids’ mental health online hub, a one-stop-shop for evidence-based mental health resources for families that includes free parenting tools, a free class on how to access mental health services in Washington state and much more.
- The Science of Well-Being for Teens | Yale Online – a free, online course for teens to build resilience.
- The Comfort Ability – Teaches kids with chronic or recurrent pain and their families how to better manage pain.
- The Meg Foundation – Empowers families with skills and support to manage pain and medical anxiety.
The barrier for families is typically finding available providers who take their insurance, so offering help on this front can be reassuring and will help them take next steps.
Q: How do you distinguish between food allergies and food intolerances and approach treatment?
This is a hard topic to discuss with families. There are different categories of how we react to food. Anaphylaxis, food allergies that present with acute GI symptoms and food sensitivities are included in the differential for food-related issues. It is common for families to want to explore how food allergies are the cause of their child’s abdominal pain. Anaphylaxis requires two or more symptoms to be involved, which may include GI. Food allergies usually refer to eosinophilic GI diseases (eosinophilic, gastric, small bowel or colonic), which overall is rare except in the case of eosinophilic esophagitis (EoE). EoE rarely presents with chronic abdominal pain, but rather presents more with chronic vomiting or dysphagia with solids.
We do not recommend allergy testing in the setting of chronic abdominal pain or functional abdominal pain. Patients can be referred to an allergist to address their specific concerns about food allergies.
Food sensitivities are much more common in functional pain. This is related to excessive overall load of certain foods, which commonly can include lactose, gluten, FODMAPs or fructose.
- Algorithm: Chronic Abdominal Pain
- Functional Abdominal Pain in Children (American College of Gastroenterology)
- Functional Abdominal Pain: How to Help With Your Child’s Chronic Abdominal Pain (Spanish) – Seattle Children’s patient handout
- Seattle Children’s GI and Hepatology referral guidelines