What is the best management approach for a 6-year-old child with chronic central abdominal pain, partially improved with omeprazole, and experiencing morning nausea and vomiting?

Management of Chronic Central Abdominal Pain in a 6-Year-Old

This child has functional abdominal pain (a disorder of gut-brain interaction), and you should stop omeprazole, initiate cognitive behavioral therapy, and consider low-dose tricyclic antidepressant therapy if symptoms remain disabling despite behavioral interventions. 1, 2

Diagnostic Clarification

This presentation meets criteria for functional abdominal pain—chronic central abdominal pain for 1 year with normal examination and basic laboratory studies, partially responsive to acid suppression but with persistent symptoms. 2, 3

Key diagnostic features supporting functional pain:

• Daily pain for 1 month with 1-year history, non-severe, no crying, described as "annoying" 2
• Normal physical examination without tenderness, guarding, or organomegaly 2
• Normal urinalysis, complete blood count, inflammatory markers, and glucose 2
• Absence of alarm features: no weight loss, no gastrointestinal bleeding, no fever, no severe progressive pain, no localized tenderness 2, 3

The ferritin of 31 is borderline low but not severely deficient and does not explain chronic abdominal pain. 2 Consider iron supplementation if dietary intake is poor, but this is not the primary issue driving symptoms.

Discontinue Omeprazole

Stop the omeprazole trial. 1, 4 The partial improvement likely represents placebo response rather than true acid-mediated pathology, given:

• Central/lower central location (not typical for acid-related dyspepsia) 1
• Pain throughout the day unrelated to meals 1
• Normal examination without epigastric tenderness 1

Prolonged proton pump inhibitor use in children carries bone health risks. 4 FDA labeling for omeprazole notes decreased femur length, cortical bone thickness, and tibial growth plate thickness in juvenile animal studies at therapeutic doses, with effects on maternal and offspring bone development. 4

Communication Strategy: The Foundation of Treatment

Establish an empathic, collaborative relationship and explain that the pain is real but represents altered pain processing in the gut-brain axis, not dangerous organic disease. 1, 2, 5

Critical communication points to parents and child:

• The pain is genuine and not imagined 1, 2
• The nervous system connecting the gut and brain has become oversensitive, amplifying normal sensations into pain signals 1, 6
• Complete pain resolution may not be achievable, but substantial improvement and return to normal activities is the goal 6, 5
• Continued medical testing will not help and may reinforce illness behavior 2, 3

First-Line Treatment: Behavioral Interventions

Initiate cognitive behavioral therapy (CBT) as first-line treatment. 1, 5, 7 CBT is the most effective intervention for pediatric functional abdominal pain, with evidence showing:

• Reduction in pain symptoms 5
• Improved school attendance 5
• Decreased healthcare utilization 1
• Addressing catastrophizing and pain-related fear avoidance 1, 6

Ensure return to normal school attendance and activities immediately. 2, 5 Avoiding activities reinforces pain behavior and worsens long-term outcomes. 5, 8

Consider gut-directed hypnotherapy if CBT is insufficient or unavailable. 6 This requires a certified clinical provider trained in pediatric hypnotherapy. 6

Pharmacologic Management: Neuromodulators

If symptoms remain disabling after 4-6 weeks of behavioral therapy, initiate low-dose tricyclic antidepressant (TCA) therapy. 1, 6

Specific dosing for pediatric functional abdominal pain:

• Start amitriptyline 10 mg at bedtime 1, 6
• Titrate slowly by 10 mg every 2-3 weeks based on response and tolerability 1
• Target dose typically 10-25 mg for this age group 1
• Explain to parents that TCAs modulate pain processing pathways, not treating depression 1, 6

Alternative if TCA not tolerated: Consider duloxetine (SNRI) for more severe symptoms, though pediatric dosing data are limited. 1, 6

Absolutely avoid opioids. 1, 6 Opioid use for functional gastrointestinal pain worsens outcomes and risks narcotic bowel syndrome. 1, 6

Additional Considerations

Screen for celiac disease if not already done, given overlapping gastrointestinal symptoms. 1 Although not mentioned in the workup, celiac serology should be obtained in children with chronic abdominal pain. 1

Assess for constipation as a contributing factor. 2, 9 Consider a therapeutic trial of fiber supplementation if constipation is suspected, even if not the primary complaint. 2

Monitor for development of anxiety or depression. 8, 3 While anxiety and depression do not distinguish functional from organic pain, they are common comorbidities requiring treatment. 3

Critical Pitfalls to Avoid

Do not order further invasive testing (endoscopy, imaging) in the absence of alarm features. 2, 3 This reinforces illness behavior, increases healthcare costs, and exposes the child to unnecessary procedural risks. 2

Do not continue empiric acid suppression beyond the current trial. 1, 4 The presentation does not support acid-mediated pathology, and prolonged PPI use carries bone health risks in children. 4

Do not dismiss the pain as "psychological" or "all in their head." 1, 6 This damages the therapeutic relationship and prevents engagement with effective treatments. 1

Recognize that 30% of children with functional abdominal pain have persistent symptoms into adulthood, making early effective intervention critical. 8, 7