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For the past four months your nine year old has been complaining of a stomachache almost daily. It hasn't really slowed him down, and it seems fairly mild.

Your 18 month old keeps pointing to her tummy and saying "ow-eeee". This has been happening on and off for several months now and you're starting to get concerned.

Your five year old has occasional bouts of severe abdominal pain. They only last for a few hours and always go away on their own. They have recently been happening more frequently and she is asking to go see the doctor.

These are all very common situations that many parents face with their children. For most kids, the pain is mild and doesn't seem bad enough to bother the doctor. Many parents may think their older child is faking or exaggerating the symptoms. Chronic abdominal pain is a very common condition, but unfortunately it is often very difficult to find the cause. Here are some guidelines to help you understand what may be causing the pain, how you can investigate it, and what signs to watch for that need medical attention.

Important note – this section deals with chronic, long-term abdominal pain. If your child is having sudden pain, or the pain has been occurring for less than one or two weeks, then see Acute Abdominal Pain for help.

1. Constipation – this is by far the most common cause of chronic abdominal pain. Here are some clues to help you decide if this is the cause:

• Occurs several times a day - as the colon contracts several times a day against the hard backed-up stool, your child will complain of cramping pain. Pain will subside after contraction stops, usually after 10 to 30 minutes.
• Child often points to the belly button as the site of pain.
• Pain can vary from mild to severe.
• Your child may have symptoms of constipation such as:
  • Straining hard to pass a bowel movement.
  • Thick, hard stools.
  • Having a bowel movement only once every few days.
• Some children can have abdominal pain from constipation but not have any other obvious signs of constipation. Some less obvious clues to possible constipation include:
  • Infrequent bowel movements.
  • Takes a long time to pass a stool. May spend 10 minutes or more on the toilet.
  • When your child does go, he passes a lot of stool.
  • Passing small, hard grape-sized pieces frequently.
  • Small stool marks soil his underwear.

If you think that constipation may be a cause of your child's abdominal pain, click on Constipation for an in-depth discussion on this topic.

2. Lactose intolerance or milk protein allergy – these two conditions are not the same thing. One is an inability to digest lactose sugar, the other is an allergic reaction throughout the body to milk proteins. Both, however, can cause upset stomach and abdominal pain. Symptoms include:

• Stomach cramps after eating dairy.
• Gas pains.
• Intestinal cramps.
• Diarrhea.
• The pain is usually crampy, gassy pain felt anywhere in the abdomen. It often is worse after eating dairy, but may come and go anytime during the day.

3. Heartburn, gastritis and ulcers – gastritis is the medical term for upset stomach or heartburn. It refers to inflammation in the stomach caused by over-production of stomach acid. Ulcers occur when this acid erodes too far into the stomach lining. Older children will describe it as a burning or gnawing pain over the upper middle or left side of the abdomen, or even the middle of the chest. Younger children can't describe a pain as "burning". There are two main causes of this over-production of acid:

• Stress – emotional stress in children can cause increased stomach acid and stomach aches.
• Infection – there is a particular bacteria called Helicobacter Pylori that can infect the stomach and cause increased stomach acid and pain. This infection can run in families. It is diagnosed either by a simple blood test or with a biopsy taken during endoscopy of the stomach. The blood test is not very reliable for children under 5 years.
• Medications – some medications can cause stomach irritation. The most common culprits are aspirin and ibuprofen products.

The treatment for gastritis or stomach ulcers is to take antacid pills before meals (Zantac 75 or Pepcid AC are two common over-the-counter ones) or after meals you can try Tums, Maalox or Mylanta. If this type of burning pain continues for more than two weeks, you should see your doctor. The treatment for H. Pylori infection is several weeks of antibiotics and antacids together.

4. Intestinal infections – there are a variety of bacteria and parasites that can infect the stomach or intestines. The pain can occur anywhere in the belly. The biggest clue that the abdominal pain may be due to an intestinal infection is the presence of chronic diarrhea. These infections are diagnosed by sending samples of the diarrhea to a lab for testing. The treatment is medication to eradicate the infection.

5. Behavioral causes – this is particularly common in children ages 4 to 7. They will complain of belly pain simply to get more attention. The pain is probably not real in this case, however, if your child's desire for attention is very strong, she may perceive the pain as real. This commonly occurs when a new baby arrives in the family – your older child may feel left out. It can also occur during a move, when starting a new school, a family tragedy or break up, or any other time when your child may feel left out, insecure or worried about something. One way to approach this situation is when your child complains of the pain, simply acknowledge her by saying something like "I know dear, sometimes my tummy hurts too. But you will be okay." Do not give any special attention to it, and do not try to help your child find a remedy. For example, do not have her lay down and you rub her tummy to make it feel better. Make some effort to give her extra attention at times when she is NOT complaining. This will lessen her need to complain for attention. There is really no way to know for sure if the pain is due to behavior or illness. Use your instinct, and do not ignore the pain longer that you feel is appropriate.

Other causes – there are many other, less common causes. These include:

• Menstrual cramps – these are usually fairly obvious – cramping lower abdominal pain may include back pain. It usually lasts 3 to 7 days at a time. Consider this cause of recurrent chronic abdominal pain if your daughter is 9 years or older. Treatment is Ibuprofen, click on it for dosing. Please note that ibuprofen can cause stomach upset.
• Tumors – this is an extremely rare occurrence in children. The doctor can often feel an abdominal mass. Do not jump to this as a possible diagnosis, because it is extremely rare.
• Organ problems – very rarely, one of the abdominal organs may have a problem. These include the liver, gallbladder, pancreas, kidneys, and spleen.

When to see the doctor. If the pain is mild and not interfering with your child's life or sleep, then it is okay to observe your child for a few weeks. The pain usually goes away on its own.If the pain is moderate to severe, then see your doctor.

Your doctor will need to know many details regarding the pain in order to evaluate its cause. Keep a diary for several weeks. Write down every day when the pain occurs, and answer the following questions with each episode:

• Time of day
• Before, after, or nowhere near a meal
• Severity on a scale of 1 to 10 – does your child simply tell you her tummy hurts, but shows no outward signs? Or does she double over in pain, holding her stomach and rolling on the floor?
• How long each episode lasts
• Where in the belly is the pain
• What do you do to help the pain – what remedies have worked, what has not worked.
• What is your child doing right before the pain occurs
• Does it awaken her at night
• Does it occur only at school, or only at home, or both
• Does it occur on the weekendsThe answers to these questions will be very valuable to your doctor, so come to your appointment well prepared.

You and your doctor will first decide if and when any testing is warranted. After talking to you, examining your child, and reviewing your pain diary, many times the doctor can diagnose the cause without any testing. If tests are necessary to determine the cause, here is a typical protocol that your doctor may follow. These tests go in order of least expensive, most helpful and most convenient, to most expensive, least helpful and least convenient:

• X-ray: this may sound extreme as the first test to do, but one simple X-ray can be very helpful, is easy to do, and fairly inexpensive. It can diagnose such things as tumors, constipation, swallowed objects, gallstones, and kidney stones.

• Urine Tests: one important hidden cause of abdominal pain you don't want to miss is a kidney problem, so your doctor will always check your child's urine.

• Stool tests: here are the various stool tests your doctor may order. They require you to pick up a special sterile container from the lab first. Ask the lab for any special instructions on collecting or storing the specimen before you bring it in:
  • Routine culture: this will look for a variety of intestinal bacterial infections such as Salmonella and E-coli.

  • Ova and Parasites (O and P): the lab will look for a variety of parasites in the stool sample.

  • Rotavirus antigen: this will detect the most common cause of diarrhea infection in infants and young children. Usually your doctor can diagnose this infection without needing this test.

  • Giardia antigen: this is a parasite, and is a fairly common cause of abdominal pain and diarrhea. It won't be found on O and P test.

  • Hemocult test: this checks for hidden blood in the diarrhea, which can help your doctor determine the cause.

• Abdominal ultrasound: this is a non-invasive test (just like a pre- natal ultrasound) that examines each specific organ in the abdomen for certain problems as well as abdominal tumors.

• Blood Tests: this checks for H.pylori stomach infection. It can also check to make sure each abdominal organ is working as it should or tell if they are being damaged by an illness.