Abdominal Pain in Children Below 2 Years of Age:Causes,Symptoms

4th Pediatric Infectious Diseases Conference

ISSN 0973 - 0958

Gastrointestinal Disorders in Children

Acute Abdominal Pain

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APPROACH TO ACUTE ABDOMINAL PAIN IN CHILDREN

Related topics

Introduction

Initial Investigation of Choice

Abdominal Pain in Children Above 2 Years

Functional Abdominal Pain and Other Motility Disorders

Investigations At Primary Care Setting and Causes

Red Flag Signs for Acute Abdominal Pain

Dr Sudipta Misra, MD
Associate Professor of Clinical Pediatrics
Chief, Section of Pediatric Gastroenterology,
Children's Hospital of Illinois, USA.

CHILDREN BELOW 2 YEARS OF AGE

At this age, abdominal pain is manifest by poor localization with non-specific signs such as crying, irritability etc. At times, it may not be obvious that the abdominal pain is the cause of the problem.

The chief concerns in this age group are

Acute intermittent recurrent episodes of abdominal pain

Intussusception

Toxin ingestion

Trauma, accidental or due to child abuse

Non GI causes of pain

Acute intermittent abdominal pain: This is the most common form of pain in children below 6 months. This may have to be differentiated from the pain of intussusception. Common causes include

Infantile colic: It is defined as at least 3 hours of inconsolable crying occurring at least 3 times a week for 3 weeks with clustering of the episodes in the evening. It usually starts early and resolves around 4-5 months of age. There may be a positive family history in siblings or parents. Though the typical picture is characteristic, atypical cases may need to be differentiated from other causes especially gastroesophageal reflux. Most of the treatment modalities are of doubtful clinical use. Tactile stimulations such as skin-to-skin contact and gentle rocking at the very onset of an episode, often associated with a change in arousal level, may abort an episode.

Gastroesophageal reflux: The esophageal symptoms of gastroesophageal reflux may cause significant irritability, crying and abdominal pain. These symptoms are likely to be caused by acid injury to the esophageal mucosa. Symptoms due to non-acid reflux (non erosive esophagitis) is a possibility but has not been documented in infants. Typically, these children present with vomiting, irritability, arching back, feeding difficulty or refusal and interrupted sleep. Associated features may include growth failure or respiratory symptoms.
Esophageal symptoms are among the 'red flag signs' for gastroesophageal reflux. It should be treated with acid suppression and anti reflux measures. If complete resolution of symptoms is not achieved, referral for specialized care should be made.

Infantile dyschezia: This typically occurs in infants in their first month of life. This children strain, cry and show other signs of distress for more than 10 minutes before defecation. Ultimately the child passes a soft stool followed by resolution of symptoms. These recurring symptoms may be stressful to the parents and mimic other serious causes of abdominal pain. The typical history is the lynch pin of diagnosis of this condition. Basically, the infant is learning to coordinate the relaxation and contraction sequences of various muscles required for successful defecation. Unsuccessful attempts of defecation are the cause of symptoms in these infants.
Most important component of management of this condition is reassuring the parents, emphasizing the pathophysiology and benign nature of the condition. As the child get his act together, the symptoms gradually improve within weeks to months. No active intervention is required. Measures like perianal stimulation may actually perpetuate the dyschezia.

Intussusception: Typically, a completely normal and healthy child between the ages of 2 months and 5 years presents with history with intermittent acute abdominal pain with pain free intervening period. The clinician should be sensitive to the possibility of intussusception in all infants in this age range with acute intermittent abdominal pain. Textbook clinical signs such as blood in stool appear late and by that time the intussusception may be irreducible and/or bowel necrosis might have set in. Clinical signs such as 'sausage' in the abdomen has been reported to be present in as much as 65% of these infants. However, in our experience, it is not a reliable clinical marker. Plain X-ray abdomen and ultrasonography are diagnostic while barium or air contrast enemas are diagnostic as well as therapeutic.

Toxin ingestion: Children acquire mobility at this age and are in oral phase of development. These children are vulnerable to accidental toxin or foreign body ingestion. The characteristic history is sudden onset of symptoms, vomiting, irritability and/or abdominal pain. Oral lesions, drooling of saliva and respiratory symptoms such as stridor or wheezing can be present with corrosives. Iron pill ingestion can cause vomiting and abdominal pain followed by hepatic failure. Vomiting and abdominal pain are the initial symptoms of suicidal attempts by acetaminophen ingestion in adolescents. A chronological history of the events leading up to the symptoms is essential. Every attempt should be made to identify the ingested agent.

Trauma: Child abuse is an important cause of abdominal pain at this age. The relationship between abdominal pain and trauma is elaborated below under 'Children above 2 years of age'.

Non-Gastrointestinal (GI) causes of pain: Infants tend to stiffen up, arch back or even draw their legs up in response to any significant pain. Due to non-specific and poorly localized nature of nociceptive response, pain caused by non-GI lesions may be mistaken for abdominal pain. Corneal foreign bodies are an important example of such pain. At times, eye examination after fluorescein instillation may be required to detect corneal abrasion. Fracture (due to child abuse), forgotten tourniquet, foreign bodies such as needles or nails lodged in the soft tissues and osteomyelitis are some other common examples non GI lesions masquerading as abdominal pain. A through examination of the infant is warranted if no apparent cause for his irritability and crying can be found.