How should I evaluate and manage abdominal pain in an otherwise healthy 8‑year‑old child?

Evaluation and Management of Stomach Ache in an 8-Year-Old

Give immediate pain relief with oral ibuprofen (5-10 mg/kg every 6-8 hours) or acetaminophen (10-15 mg/kg every 4-6 hours) without waiting for a diagnosis, as pain control improves examination quality and does not mask symptoms or affect diagnostic accuracy. 1, 2

Immediate Pain Management

• Administer oral NSAIDs (ibuprofen) as first-line treatment for mild-to-moderate pain if no contraindications exist (no gastrointestinal bleeding, severe dehydration, or renal disease). 1, 2
• For severe pain unresponsive to oral medications, use intravenous opioids (morphine) in small, titrated doses via IV route for rapid relief. 1, 2
• Never withhold analgesia while awaiting diagnosis—this outdated practice impairs examination without improving diagnostic accuracy, as demonstrated in multiple pediatric studies. 1, 2

Identify Red Flags Requiring Urgent Evaluation

Perform focused history and physical examination looking specifically for alarm features that indicate serious pathology:

• Gastrointestinal bleeding (bloody stools, melena, hematemesis) requires immediate escalation. 1
• Bilious or persistent vomiting suggests bowel obstruction. 1
• Fever with localized right lower quadrant pain raises concern for appendicitis. 1
• Severe or progressive pain that increases in intensity is a red flag. 1
• Abdominal tenderness, guarding, rigidity, or distension on examination requires urgent attention. 1
• Signs of dehydration or inability to tolerate oral intake warrant immediate intervention. 1
• Difficulty walking, rebound tenderness, or psoas/obturator signs are significantly associated with appendicitis. 3

Initial Diagnostic Workup

• Obtain urinalysis in all children to exclude urinary tract infection, which frequently mimics surgical emergencies. 1
• Check complete blood count with differential and C-reactive protein if appendicitis is suspected—CRP ≥10 mg/L and WBC ≥16,000/mL are strong predictive factors for appendicitis in pediatric patients. 3
• Absolute neutrophil count >6,750/mm³ is significantly associated with acute appendicitis in children. 3
• Plain abdominal radiography may identify constipation or lower-lobe pneumonia in low-risk patients but has limited diagnostic value otherwise. 1

Imaging Strategy Based on Risk Stratification

• Children with low clinical risk for appendicitis do not require imaging; instead pursue evaluation for other causes such as constipation, gastroenteritis, or urinary tract infection. 1
• For intermediate or high clinical risk, ultrasound of the right lower quadrant is the preferred initial imaging modality (sensitivity ~76%, specificity ~95%) without radiation exposure. 1
• If ultrasound is nondiagnostic and clinical suspicion remains high, use MRI without or with IV contrast (sensitivity 86-94%, specificity 94%) to avoid radiation. 1
• Reserve CT abdomen/pelvis only for cases where ultrasound is inconclusive and clinical suspicion remains high. 1

Antibiotic Stewardship

• Do not routinely prescribe broad-spectrum antibiotics for children with fever and abdominal pain when there is low suspicion of complicated infection. 1, 4
• Reserve antibiotics for confirmed complicated intra-abdominal infections (perforated appendicitis with abscess), using aminoglycoside-based combinations, carbapenems, piperacillin-tazobactam, or advanced-generation cephalosporins with metronidazole. 1, 4
• Discontinue antibiotics within 24 hours if signs of infection resolve and source control is adequate. 1

Management of Functional Abdominal Pain (If No Red Flags Present)

If examination reveals no alarm features and workup is negative:

• Explain to parents that symptoms are real but not dangerous, establishing realistic expectations that complete pain resolution may not be achievable. 1
• Focus on maintaining normal activities and quality of life rather than complete symptom elimination. 1
• Consider therapeutic trial of fiber (25 g/day) if constipation is suspected, particularly if pain is relieved by defecation. 1
• For meal-related pain, consider antispasmodic (anticholinergic) medication. 1
• Cognitive behavioral therapy and hypnotherapy have demonstrated benefit for functional abdominal pain in children. 5, 6

Critical Pitfalls to Avoid

• Never withhold pain medication while awaiting diagnosis—this causes unnecessary suffering and impairs examination quality. 1, 2
• Avoid routinely ordering imaging or antibiotics in low-risk patients—reserve for those with red-flag symptoms or intermediate/high clinical risk. 1
• Recognize that children under 5 years present atypically with significantly higher perforation rates due to delayed diagnosis, requiring heightened vigilance. 1
• Do not use intramuscular route for opioids—it is painful and does not allow adequate titration. 2

Follow-Up Instructions

• Instruct parents to return immediately if severe or progressive pain develops, fever with localized pain occurs, bilious vomiting appears, or the child cannot tolerate oral intake. 1
• For persistent symptoms despite initial management, re-evaluate in 3-6 weeks and consider additional symptom-directed investigations. 1