What is the best approach to manage anxiety-induced stomach aches in children?

Management of Anxiety-Induced Stomach Aches in Children

Begin with cognitive behavioral therapy (CBT) or gut-directed hypnotherapy as first-line treatment, combined with education about the brain-gut connection, and avoid pharmacological interventions unless psychological therapy alone proves insufficient. 1, 2

Initial Approach: Education and Relationship Building

• Explain to the child and parents that the pain is real and originates from altered pain processing in the brain-gut axis, not from tissue damage or inflammation. 1
• Emphasize that central nervous system factors maintain and amplify pain through mechanisms like central sensitization and altered pain modulation pathways. 1
• Building an empathic, collaborative relationship directly impacts treatment success and should be prioritized from the first encounter. 1

First-Line Non-Pharmacological Interventions

Cognitive Behavioral Therapy (CBT):

• Initiate CBT early as it produces the strongest evidence for long-term symptom improvement in children with functional abdominal pain. 1, 2
• CBT focuses on remediation of pain catastrophizing, pain hypervigilance, and visceral anxiety through cognitive reframing, exposure, relaxation training, and flexible problem solving. 3
• Can be delivered in multiple formats including self-administered, web-based, group, or individual sessions (typically 4-12 sessions). 3, 4
• Internet-delivered CBT based on exposure exercises shows large effect sizes (Cohen d=1.14) with 81% of children completing treatment and 90% reporting symptom improvement. 4

Gut-Directed Hypnotherapy:

• Consider hypnotherapy as an equally effective first-line option, particularly for functional abdominal pain and anxiety-related gastrointestinal symptoms. 1, 2
• This approach focuses on somatic awareness and down-regulation of pain sensations through guided imagery and posthypnotic suggestions. 3
• Long-term follow-up studies show superiority to standard care, with 68% remission rate at 5 years compared to 20% in control groups. 3
• Can be delivered by non-mental health professionals after appropriate training. 3

Guided Imagery:

• Use home-based guided imagery with audio recordings, which demonstrates significantly greater decrease in pain days compared to standard care. 1, 2
• This technique invokes all senses and produces measurable physiologic changes in stress and immune biomarkers. 3

Environmental and Supportive Strategies

Stress Management Techniques:

• Incorporate distraction techniques such as bubble blowers, pinwheels, videos, music, or imagery projectors to decrease anxiety and pain perception. 3, 5
• Use controlled breathing, progressive relaxation, and mindfulness-based approaches, which improve cognitive appraisal of symptoms and quality of life. 3
• Involve child life specialists or trained professionals in nonpharmacologic stress reduction, as they can teach age-appropriate coping strategies and support family involvement. 3

Family Involvement:

• Teach parents to decrease attention to pain behaviors while reinforcing and supporting the child's work with exposure exercises. 4
• Family presence and active participation in the treatment process is essential for effectiveness. 3

When to Consider Pharmacological Management

Low-Dose Tricyclic Antidepressants:

• Consider starting low-dose amitriptyline only if psychological therapy alone is insufficient. 1
• This can be managed by primary care or gastroenterology providers as baseline therapy. 1

Anxiolytic Medications (Limited Role):

• Hydroxyzine is a sedative antihistamine approved for anxiolytic use with few contraindications in children, but should be reserved for acute procedural anxiety rather than chronic management. 3

Critical Pitfalls to Avoid

Never prescribe opioids as they cause narcotic bowel syndrome, worsen gastrointestinal symptoms, and increase risk of dependence and hyperalgesia. 1

Avoid antimotility drugs like loperamide in children due to serious side effect risks. 1, 2

Do not delay psychological interventions by exhausting all medical options first, as this frames mental health treatment as a "last resort" and reduces patient acceptance. 3

Screen for trauma history using patient-friendly language, as past sexual, physical, or emotional abuse increases risk of developing anxiety-related abdominal pain and affects treatment response. 3

When to Escalate Care

• Refer to a multidisciplinary pain team when symptoms remain severe or disabling despite first-line psychological therapy. 1
• Consider referral to a psychologist or psychiatrist when significant psychiatric comorbidities (depression, post-traumatic stress, eating disorders) are present. 3, 1
• Assess for avoidant-restrictive food intake disorder, as this is a contraindication for restrictive dietary therapy and requires specialized mental health intervention. 3

Assessment Considerations

• Identify symptom-specific anxiety and cognitive factors that influence symptom perception, such as pain catastrophizing and hypervigilance. 3
• Recognize that factors triggering the child's symptoms may differ from factors maintaining them over time. 3
• Use validated pain and anxiety scales adapted to the child's age for ongoing assessment. 3