What is the recommended management for abdominal pain in pediatric patients?

Management of Abdominal Pain in Pediatric Patients

Administer pain medication immediately upon presentation—do not withhold analgesics while awaiting diagnosis, as this outdated practice impairs examination without improving diagnostic accuracy. 1, 2

Immediate Pain Assessment and Relief

Pain assessment must begin at first contact (including prehospital) and continue through discharge. 1

Analgesic Selection by Pain Severity

For mild to moderate pain:

• Administer oral ibuprofen 5-10 mg/kg every 6-8 hours OR acetaminophen 10-15 mg/kg every 4-6 hours as first-line treatment if no contraindications exist 2, 3
• Oral opioids are appropriate for moderate pain if the patient can tolerate oral medications 1

For severe pain:

• Administer IV opioid analgesics (morphine) titrated to effect using small, controlled doses 1, 2, 4
• Alternative routes include intranasal, transmucosal, or inhaled fentanyl when IV access is unavailable, though intranasal may cause nasal mucosal burning 1
• Avoid the intramuscular route—it is painful, does not allow titration, and causes days of injection site pain 1, 2

Critical Evidence on Analgesics and Diagnosis

Multiple adult and pediatric studies demonstrate that opioids (including morphine) do not mask symptoms, cloud mental status, or impair diagnostic accuracy in abdominal pain. 1, 2, 4 In fact, pain relief makes children more comfortable and facilitates abdominal examination and diagnostic testing (such as ultrasonography), thereby aiding diagnosis. 1, 4

Age-Specific Diagnostic Approach

Neonates and Young Infants

• Eliminate unnecessary painful procedures (heel sticks, intramuscular injections) when possible 1
• Venipuncture is less painful than heel lancing for blood sampling 1
• When intramuscular route is necessary, use topical anesthetic 1
• Provide adequate pain prophylaxis for procedures and appropriate pain relief 1

All Pediatric Age Groups

The differential diagnosis varies significantly by age—consider gastroenteritis, constipation, urinary tract infection, acute appendicitis, tubo-ovarian abscess, testicular torsion, and volvulus based on age-appropriate likelihood. 5

Specific Condition Management

Gastroenteritis-Related Abdominal Pain

Assess dehydration status first using physical examination: 2

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

ORS administration technique:

• Start with 5 mL every minute using teaspoon, syringe, or medicine dropper, gradually increasing as tolerated 2
• Replace ongoing losses: 10 mL/kg per watery stool and 2 mL/kg per vomiting episode 2

Dietary management:

• Continue age-appropriate feeding during rehydration—do not withhold nutrition 2
• Breastfed infants continue nursing on demand 2
• Formula-fed infants receive full-strength, lactose-free or lactose-reduced formula immediately upon rehydration 2
• Older children continue usual diet including starches, cereals, yogurt, fruits, vegetables; avoid foods high in simple sugars and fats 2

Avoid antidiarrheal agents (loperamide, kaolin-pectin)—they do not reduce diarrhea volume or duration and carry risks including ileus, drowsiness, and death. 2

Suspected Appendicitis

Physical examination findings suggestive of appendicitis:

• Decreased or absent bowel sounds, psoas sign, obturator sign, Rovsing sign, right lower quadrant rebound tenderness 5
• Use validated scoring systems like the Pediatric Appendicitis Score to determine risk 1, 5

Imaging approach:

• Ultrasound is the initial imaging study for right lower quadrant pain to avoid radiation exposure 4, 6
• CT may be considered if ultrasound is inconclusive and clinical suspicion for surgical pathology remains 4

Antibiotic therapy for complicated appendicitis:

• Acceptable regimens include aminoglycoside-based, carbapenem, piperacillin-tazobactam, or advanced-generation cephalosporin with metronidazole 3, 4
• In children with complicated appendicitis, early switch (after 48 hours) to oral antibiotics with overall therapy <7 days is safe and cost-effective 1
• No postoperative antibiotics are needed for uncomplicated appendicitis 1

GERD-Related Abdominal Pain

Implement lifestyle modifications before pharmacologic treatment: 2

• For breastfed infants: Trial maternal exclusion diet restricting milk and egg for 2-4 weeks 2
• For formula-fed infants: Consider extensively hydrolyzed protein or amino acid-based formula for 2-4 weeks 2
• Thickened feedings: Up to 1 tablespoon dry rice cereal per 1 oz formula or commercially thickened formulas 2
• Critical warning: Never use thickening agents in preterm infants (<37 weeks gestation) due to necrotizing enterocolitis risk 2

Red Flags Requiring Immediate Surgical Evaluation

Refer urgently for surgical consultation if any of the following are present: 1, 2, 5

• Pain that is severe, localized, and increasing in intensity 5
• Pain preceding vomiting 5
• Bilious vomiting 5
• Hematochezia 5
• Guarding and rigidity 5
• Signs of bowel obstruction 2, 3
• Severe or persistent pain despite treatment 2, 3
• Signs of dehydration with inability to tolerate oral intake 2, 3
• Decreased urine output, irritability, or lethargy 2
• Intractable vomiting 2

Nonpharmacologic Interventions

Incorporate child life specialists and others trained in nonpharmacologic stress reduction to alleviate anxiety and perceived pain. 1

Family presence during painful procedures is viable and useful in the acute care setting. 1

Use distraction techniques to improve pain management in children. 1

Discharge Instructions

Provide pain medication on discharge even for mild to moderate pain, with specific instructions regarding dose and duration. 1

Pain medication should be recommended around-the-clock for anyone in whom moderate pain is anticipated. 1

Give clear, written instructions for families regarding aftercare, especially for children who received procedural sedation. 1

Critical Pitfalls to Avoid

Never withhold pain medication while awaiting diagnosis—this impairs examination without improving diagnostic accuracy. 1, 2, 3, 4

Do not routinely prescribe broad-spectrum antibiotics for all children with fever and abdominal pain—reserve for confirmed complicated infections. 2, 3

Avoid prolonged use of restrictive diets (BRAT diet alone or diluted formulas)—these result in inadequate energy and protein intake. 2

Do not use intramuscular injections when other routes are available—they are painful and prevent titration. 1, 2