What are the treatment options for pediatric stomach pain?

Pediatric Stomach Pain Treatment

Treatment of pediatric stomach pain should prioritize immediate pain relief without withholding analgesia while awaiting diagnosis, as pain control facilitates better examination and does not affect diagnostic accuracy. 1, 2

Immediate Pain Management

Administer oral NSAIDs (ibuprofen 5-10 mg/kg every 6-8 hours) or acetaminophen (10-15 mg/kg every 4-6 hours) as first-line treatment for mild to moderate pain if no contraindications exist. 1, 2

• For severe pain unresponsive to oral agents, administer intravenous opioid analgesics (such as morphine) titrated to effect using small, controlled doses 1, 2, 3
• Avoid the intramuscular route as it is painful and does not allow adequate titration 2
• Multiple studies demonstrate that analgesics, including morphine, do not mask symptoms or impair diagnostic accuracy 2, 3

Contraindications to NSAIDs

• Suspected active gastrointestinal bleeding 2
• Severe dehydration 2
• Renal compromise 2

Gastroenteritis-Related Abdominal Pain

Assessment of Dehydration Status

Evaluate degree of dehydration using physical examination findings before initiating treatment. 4

• Mild dehydration (3%-5% fluid deficit): Administer 50 mL/kg of oral rehydration solution (ORS) containing 50-90 mEq/L sodium over 2-4 hours 4
• Moderate dehydration (6%-9% fluid deficit): Administer 100 mL/kg of ORS over 2-4 hours 4
• Severe dehydration (≥10% fluid deficit, shock): This is a medical emergency requiring immediate IV boluses of 20 mL/kg Ringer's lactate or normal saline until pulse, perfusion, and mental status normalize 4

Oral Rehydration Technique

• Start with small, frequent volumes (5 mL every minute) using a teaspoon, syringe, or medicine dropper 4
• Gradually increase volume as tolerated 4
• Replace ongoing losses: 10 mL/kg for each watery stool and 2 mL/kg for each vomiting episode 4
• Simultaneous correction of dehydration often lessens vomiting frequency 4

Dietary Management During Gastroenteritis

Continue age-appropriate feeding during rehydration—do not withhold nutrition. 4

• Breastfed infants: Continue nursing on demand 4
• Formula-fed infants: Administer full-strength, lactose-free or lactose-reduced formulas immediately upon rehydration 4
• Older children: Continue usual diet including starches, cereals, yogurt, fruits, and vegetables; avoid foods high in simple sugars and fats 4

Medication Considerations for Gastroenteritis

Neither antibiotics nor nonspecific antidiarrheal agents are usually indicated for acute diarrhea. 4

• Consider antibiotics only when: dysentery or high fever is present, watery diarrhea persists >5 days, or stool cultures indicate a treatable pathogen 4
• Antidiarrheal agents (loperamide, kaolin-pectin) do not reduce diarrhea volume or duration and carry risks including ileus, drowsiness, and even death 4
• Ondansetron may be used to prevent vomiting and improve tolerance of oral rehydration in moderate dehydration 5

Gastroesophageal Reflux Disease (GERD)

Lifestyle Modifications (First-Line)

Implement feeding changes and positioning therapy before considering pharmacologic treatment. 4

• For breastfed infants: Trial maternal exclusion diet restricting milk and egg for 2-4 weeks 4
• For formula-fed infants: Consider extensively hydrolyzed protein or amino acid-based formula for 2-4 weeks 4
• Thickened feedings: Add up to 1 tablespoon dry rice cereal per 1 oz formula or use commercially thickened formulas 4
  • Critical warning: Do not use thickening agents in preterm infants (<37 weeks gestation) due to necrotizing enterocolitis risk 4
• Reduce feeding volume while increasing frequency 4
• Avoid overfeeding, seated positions, supine positioning, and environmental tobacco smoke 4

Pharmacologic Treatment for GERD

When lifestyle modifications fail and complications exist (poor weight gain, anemia, recurrent pneumonia, hematemesis):

• Proton pump inhibitors: Lansoprazole is FDA-approved for pediatric GERD and erosive esophagitis in children ≥1 year old 6
• H2 receptor antagonists: Ranitidine dosing for pediatric GERD is 5-10 mg/kg/day in 2 divided doses (maximum 300 mg/day) 7

Red Flags Requiring Immediate Evaluation

Recognize warning signs that mandate urgent further assessment: 1, 3

• Signs of bowel obstruction 1
• Severe or persistent pain despite treatment 1
• Signs of dehydration with inability to tolerate oral intake 1
• Decreased urine output, irritability, or lethargy 4
• Intractable vomiting 4

Critical Pitfalls to Avoid

• Never withhold pain medication while awaiting diagnosis—this outdated practice impairs examination without improving diagnostic accuracy 1, 2, 3
• Do not routinely prescribe broad-spectrum antibiotics for all children with fever and abdominal pain; reserve for confirmed complicated infections 1
• Avoid prolonged use of restrictive diets (such as BRAT diet alone or diluted formulas), which can result in inadequate energy and protein intake 4
• Do not use improperly diluted ORS—incorrect formulation can cause severe complications including gastrointestinal hemorrhage 8