What is the best course of treatment for a child experiencing abdominal pain?

Management of Stomach Ache in Small Children

For children with abdominal pain, a stepwise approach starting with lifestyle modifications and oral rehydration therapy is recommended as first-line treatment, with medications reserved for specific causes and more severe cases. 1

Initial Assessment and Management

• Assess for signs of dehydration including abnormal capillary refill, abnormal skin turgor, and abnormal respiratory pattern, which are the most useful predictors of significant dehydration 2
• For mild to moderate abdominal pain without signs of complicated infection, broad-spectrum antibiotics are not indicated 1
• Pain medication should be administered promptly for children in pain, as there is no evidence that pain management masks symptoms or affects diagnostic accuracy 1
• For abdominal pain associated with gastroenteritis, oral rehydration therapy is the cornerstone of treatment 3, 2

Specific Management Strategies by Cause

For Gastroesophageal Reflux (GER)

• For infants with symptoms mimicking GER, consider a 2-4 week trial of maternal exclusion diet (restricting milk and eggs) for breastfed infants 1
• For formula-fed infants, consider changing to a protein hydrolysate formula thickened with 1 tablespoon rice cereal per ounce 1
• Avoid overfeeding and avoid seated and supine positions immediately after feeding 1

For Gastroenteritis

• Oral rehydration with appropriate solutions is equally effective as intravenous rehydration for most cases of mild to moderate dehydration 2, 4
• Continue breastfeeding during episodes of acute gastroenteritis 3
• Both glucose-based and rice syrup solids-based oral rehydration solutions are effective for rehydration 4
• Food-based oral rehydration solutions may reduce stool output compared to standard glucose-based solutions 5
• Consider probiotics (particularly Lactobacillus rhamnosus GG, Lactobacillus reuteri, and Saccharomyces boulardii) to reduce duration and severity of diarrhea 3

For Complicated Intra-abdominal Infections

• If complicated intra-abdominal infection is suspected, selection of antimicrobial therapy should be based on the origin of infection, severity of illness, and safety considerations for the specific pediatric age group 1
• Acceptable antimicrobial regimens include aminoglycoside-based regimens, carbapenems, β-lactam/β-lactamase inhibitor combinations, or advanced-generation cephalosporins with metronidazole 1
• For children with severe reactions to β-lactam antibiotics, ciprofloxacin plus metronidazole or an aminoglycoside-based regimen can be used 1

Pain Management

• For mild to moderate pain, oral analgesics including nonsteroidal anti-inflammatory drugs are appropriate if there are no contraindications 1
• For severe pain, systemic opioid pain medication may be administered through various routes including intravenous or transmucosal 1
• Ondansetron may be effective in decreasing vomiting, improving success with oral hydration, and preventing the need for IV hydration in children with gastroenteritis 2
• For infants under 6 months, consider using 2 mL of 25% sucrose solution administered by syringe into the infant's mouth or with a pacifier 2 minutes before painful procedures 1

Non-Pharmacological Approaches

• Mind-body therapies such as biofeedback, guided imagery, and relaxation techniques may be helpful for functional abdominal pain 1
• Chest physiotherapy is not beneficial for children with pneumonia and should not be performed 1
• For respiratory issues with abdominal pain, a supported sitting position may help expand lungs and improve symptoms 1

Special Considerations

• For neonates with necrotizing enterocolitis, management includes fluid resuscitation, intravenous broad-spectrum antibiotics, and bowel decompression 1
• Nasogastric tubes may compromise breathing and should be avoided in severely ill children, especially infants with small nasal passages 1
• If intravenous fluids are needed, they should be given at 80% of basal levels with monitoring of serum electrolytes 1

Follow-up Recommendations

• For children whose signs and symptoms of infection have resolved, no further antibiotic therapy is required 1
• For children recovering from intra-abdominal infection who require continued antibiotics, oral step-down therapy guided by culture results should be considered 1
• Patients with persistent or recurrent signs of peritoneal irritation, failure of bowel function to return to normal, or continued fever require additional evaluation 1