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Primary care management and referral guideline Primary care management and referral guideline

Chronic Abdominal Pain in Children and Adolescents – Management and referral guideline

Red flags

  • Blood in stools
  • Unexplained fever
  • Poor weight gain or significant weight loss
  • Abuse or neglect
  • Diarrhoea lasting > 4 weeks

Purpose

Primary care management and referral guidelines contain condition-based information for GPs about when to refer a patient, assessment and management measures that should be taken prior to submitting a referral, and what should be included in a referral to the relevant outpatient department or specialist service.

Introduction

  • Chronic abdominal pain is common in children and adolescents.
  • The differential diagnosis is broad, and careful history‑taking and examination are required.
  • In most cases, chronic abdominal pain is a manifestation of a functional disorder (e.g., functional abdominal pain, abdominal migraine, functional dyspepsia, irritable bowel syndrome (IBS)), and less often a symptom of organic pathology.
  • Patients with organic pathology (e.g., infection, coeliac disease, inflammatory bowel disease (IBD)) are more likely to present with other symptoms and abnormal physical examination findings (e.g., vomiting, abdominal tenderness, blood in stools, weight loss or failure to thrive).

Assessment

Perform thorough assessment
Perform a thorough assessment both to exclude an organic cause and establish a strong therapeutic relationship.

Take a comprehensive, age appropriate history and check:

  • symptoms.

    Symptoms

    • Onset, time of the day, frequency if intermittent, duration of episodes, severity, impact on daily activities
    • Location of the pain and if radiated or not
    • Stool history for:
      • frequency, consistency (diarrhoea or constipation)
      • blood or mucous – suggests inflammation (protein intolerance, inflammatory bowel disease (IBD), infection)
    • Associated symptoms:
      • Bloating, diarrhoea, constipation
      • Fever, night sweats
      • Weight loss or failure to thrive
      • Pubertal delay
      • Anorexia, dyspepsia, difficulty or pain swallowing and vomiting
      • Mouth ulcers
      • Skin rashes, subcutaneous swelling
      • Headaches
      • Lower urinary tract symptoms
  • potential triggers, and relieving factors e.g., defecating, eating.

    Triggers

    • Recent gastrointestinal (GI) infection
    • Eating specific foods
    • Stressful event (e.g., parental conflict, new school)
    • Menses (e.g., endometriosis, dysmenorrhoea)
    • Medications (e.g., antibiotics, NSAIDs)
  • dietary history for specific food triggers e.g., gluten, cow’s milk, as well as age of introduction.
  • psychosocial factors causing or impacting the pain experience.

    Psychosocial factors

    • School attendance, home situation, emotional difficulties, mental health (e.g., depression, anxiety)
    • Signs of abuse or neglect

    For adolescents, see The Royal Children’s Hospital Melbourne – Engaging With and Assessing the Adolescent Patient.

  • family history e.g., coeliac, irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), peptic ulcer.

Consider asking the patient or parent to complete a food and symptom diary and record time of day, pain features (e.g., location, severity, duration), possible triggers, treatments trialled, and impact on activities.

Perform an age appropriate examination:

  • Check general appearance, alertness, hydration status, and vital signs. Determine if the patient is seriously ill.
  • Record height and weight. Plot in an appropriate growth chart, and check for failure to thrive.
    Poor growth
    Consider poor growth if any of:

    • Growth crossing down over centile lines
    • Weighing less than:
      • 6 kg at 6 months
      • 8 kg at 1 year
      • 10 kg at 2 years
      • 16 kg at 5 years
  • Palpate for lymphadenopathy (e.g., inguinal, supraclavicular, axillary, neck).
  • Check for mouth ulcers and conjunctival pallor (signs of IBD).
  • Check abdomen for localised tenderness, guarding, palpable masses (e.g., hepatosplenomegaly, faecal mass), distension, bowel sounds.
  • Check Carnett’s sign.

    Carnett’s sign

    • Check if abdominal tenderness is unchanged or increased when the patient lifts their head and shoulders off the bed compared to when supine.
    • If increased, this suggests abdominal wall pain, instead of an intra‑abdominal cause.
  • Check skin and joints for signs of auto immune disease e.g., rash, synovitis.
  • Consider checking perianal area for fissures, fistulas, erythema, or skin tags (signs of Crohn’s disease).
    • Digital rectal examination in primary care for children is not recommended.
    • If performing genital‑anal examination, follow recommended protocol and consider a chaperone.

      Recommended protocol

      • Only perform a genital examination if there is a specific and clear clinical indication.
      • Always seek voluntary consent from the parent or guardian, and the child or young person.
        • Explain the purpose of the examination and only proceed if the child or young person consents. Do not proceed if the child refuses to cooperate.
        • Consider capacity to consent of patients who are physically, mentally, or intellectually impaired, and those of culturally or linguistically diverse background (amongst others).
      • Always consider:
        • the presence of a chaperone in the room. Adolescents are entitled to decline this, and the doctor may decline conducting the examination if a chaperone is declined by the patient.
        • needs of infants and younger children – allow the parent or guardian to remain close to the child or hold the child on their lap during the examination.
        • needs of older children and adolescents – allow them to undress or dress in private and wear a gown for the examination.
        • the patient’s specific needs, e.g. if disabled or of culturally or linguistically diverse background.
      • If relevant, discuss and explain limits of confidentiality with adolescents.

Consider differential diagnosis.

Differential diagnosis
List not exhaustive:

  • Functional gastrointestinal (GI) disorders (most common)
    Functional gastrointestinal (GI) disorders
    Suspect if patient with no concerning features on history and examination – see Rome IV criteria (section H2, page 4 of document).

  • Food allergies and intolerance (e.g., coeliac disease, lactose intolerance, fructose intolerance, cow’s milk allergy)

    Food allergies and intolerance

    • Food allergies are a rare cause of abdominal pain. Other causes should be ruled out first as restrictive diets may lead to nutritional deficiencies with limited or no benefit.
    • Rapid onset reactions are likely to be diagnosed and treated early but those with delayed or very delayed reactions may be difficult to diagnose and may present with chronic abdominal pain.
    • Suspect if:
      • symptoms occurring within a few hours to a couple of days of consuming the offending food.
      • associated diarrhoea, vomiting, bloating, and poor weight gain.
    • May also cause other non‑GI symptoms e.g., eczema, headaches, irritability or mood changes
    • Consider:
      • coeliac disease – iron deficiency anaemia may be present.
      • food protein‑induced allergic disorders e.g., food protein‑induced proctocolitis (cow’s milk protein allergy), food protein-induced enterocolitis syndrome (FPIES).
  • Inflammatory or infectious conditions

    Inflammatory or infectious conditions

    • Inflammatory bowel disease – gradual onset diarrhoea with or without blood in stools with progressive weight loss or failure to thrive (more common in late childhood or early adolescence)
    • Giardiasis or parasitic infection
    • Mesenteric adenitis
  • GORD or peptic ulcer disease
  • Hepatobiliary disease (e.g., cholelithiasis, hepatitis, chronic pancreatitis)
  • Urological conditions (e.g., UTI, urolithiasis)
  • Gynaecological conditions in teenage girls (e.g., dysmenorrhoea, endometriosis)
  • Heavy metal toxicity (e.g., lead)
  • Malignancy (e.g., lymphoma, neuroblastoma)

Investigations:

  • Consider baseline investigations:
    • FBC, inflammatory markers, E/LFTs, and coeliac serology

      Coeliac serology

      • Arrange tissue transglutaminase (anti‑tTG IgA and total IgA).
      • If IgA deficiency, request deamidated gliadin peptide (DGP IgG) antibodies.
      • The patient must still be eating gluten for 6 weeks before the test (e.g., 2 pieces of bread daily).
      • If patient unwilling to return to a gluten containing diet, arrange HLA DQ gene test as well as anti‑tTG IgA and total IgA.

        HLA DQ gene test

        • The presence of these genes indicates a risk of susceptibility for coeliac disease.
        • These genes are present in 30% of the population.
        • A negative test for these genes excludes coeliac disease.
    • Stool examination

      Stool examination

      • Inspection
      • Microscopy for ova, cysts, and parasites, red and white blood cells, fat globules, and fatty acid crystals
      • Culture and sensitivity (including Giardia antigen)
      • PCR assay – interpret with caution and consider colonising flora (e.g., Dientamoeba fragilis, Blastocystitis spp.) with limited clinical relevance
    • Urine MCS
  • Consider imaging:
    • Consider abdominal ultrasound if suspected biliary cause, mesenteric adenitis, or abdominal mass.
    • Only arrange abdominal X‑ray if considering acute gastrointestinal obstruction.
    • Arrange chest X-ray if there is associated fever, tachypnoea, respiratory distress, or suspicious chest auscultatory findings. Pneumonia in children may present with abdominal pain.
    • Do not request abdominal CT in children in primary care unless under specialist advice.
  • Arrange other investigations as indicated on a case by case basis if other underlying pathology suspected.

Management

If suspected child neglect or abuse, ensure the child’s safety.

Ensure the child’s safety

  • Contact child safety services immediately and manage according to their advice.
  • If signs of physical abuse (inflicted injury), or child at imminent risk of harm, consider transfer by ambulance to your nearest ED.
  • Clearly document the event.

If infection indicated by stool examination and:

If blood in stools, unexplained fever, poor weight gain or significant weight loss, diarrhoea lasting > 4 weeks, or organic pathology suspected (i.e., abnormal history, examination, or investigation):

  • follow the relevant guideline (if available) e.g., coeliac disease in children.
  • Refer to your local General Paediatrics service (especially if undifferentiated abdominal pain) or refer to your local paediatric gastroenterology service

If organic pathology ruled out, manage as a functional gastrointestinal disorder and follow relevant guideline if available. Consider:

Reassure and educate parents and patients. Discuss:

Reassurance

  • serious pathology has been adequately ruled out.
  • additional investigations are not recommended.
  • functional abdominal pain is benign and will likely improve with time and general measures only.
  • medications have a very limited role in the management of functional abdominal pain.
  • trigger avoidance.

    Trigger avoidance

    • Dietary restriction should not be routinely recommended, as this can lead to significantly restricted diets with nutritional deficiencies and limited or no benefit to the child.
    • If considering, recommend a short‑term trial (e.g., 4 weeks) of elimination of one food at a time and only if there is a clear temporal association between the ingestion of the food and the onset of symptoms. Follow up regularly and reinstate the food if no improvement noted.
    • Some potential triggers include (not exhaustive):
      • gas‑producing foods
      • caffeinated or carbonated drinks
      • lactose
      • fatty or spicy foods
      • citrus
      • wheat or gluten – do not recommend a gluten‑free diet in patients not diagnosed with coeliac disease
    • Consider referring to a dietitian for assessment and support.
  • behaviour modification.

    Behaviour modification

    • Encourage return to normal day‑to‑day activities e.g., participation in sports, school attendance.
    • Discourage abnormal pain behaviour e.g., prolonged rest, social isolation, avoiding activities because of fear of pain.

    See also ACI – PainBytes.

  • environmental stressors.

    Environmental stressors

    • Encourage a supportive home and school environment.
    • Address school absenteeism, bullying, and other psychosocial issues.
    • Manage anxiety:
      • Consider referring for psychological assessment and support.
      • Recommend support programs for children and adolescents with anxiety (e.g., The Brave Program).
  • chronic pain management and coping strategies.

    Chronic pain management and coping strategies

    • Explain that chronic pain does not necessarily indicate organic pathology, but that the pain is real to the child.
    • Discuss distraction and relaxation techniques (e.g., muscle relaxation, deep breathing) and smartphone apps (e.g., Smiling Mind, Headspace).
    • Consider referring for psychological assessment and CBT or behavioural pain management if not responding to other measures.
    • Consider a short‑term (e.g., 4 weeks) trial of any of:
      • peppermint oil
      • probiotics
      • water‑soluble fibre (if associated abnormal bowel movements)
    • Discuss use of simple analgesics (e.g., NSAIDs, paracetamol) unless contraindicated. Reinforce sparing use only and without exceeding recommended dosing.
    • Do not prescribe antidepressants for the management of functional abdominal pain unless under specialist advice.

    See also ACI – PainBytes.

If suspected mental health issues (e.g., anxiety, depression):

  • Consider referring for psychological assessment and support.
  • Recommend support programs for children and adolescents with anxiety (e.g., The Brave Program).
  • If more significant pathology suspected, and if eligible, refer to your local child and youth mental health service, if available

Offer ongoing support:

  • Arrange follow‑up at regular intervals e.g., fortnightly or monthly.
  • Advise parents and patient to return at any stage if any concerning signs or symptoms develop (e.g., blood in stools, vomiting, fevers).
  • Be prepared to re‑evaluate symptoms, address any emerging concerns, and review diagnosis if indicated.
  • If ongoing concerns, discuss with your local general paediatric team or paediatric gastroenterology team

When to refer

  • If suspected child neglect or abuse, contact child safety services immediately.
  • If signs of physical abuse (inflicted injury) or child at imminent risk of harm, consider discussing with your local paediatric team on call or arrange transfer to your nearest ED as appropriate
  • If any other red flags or organic pathology suspected (i.e., abnormal history, or examination, or investigation), refer to your local paediatric gastroenterology service or local general paediatrics service
  • Consider referring to a dietitian for assessment and support for trigger avoidance.
  • If suspected mental health issues:
    • Consider referring for psychological assessment and support.
    • If more significant pathology suspected,  and if eligible, refer to your local child and youth mental health service, if available
  • If ongoing concerns, discuss with your local general paediatric team or paediatric gastroenterology team.

Referring to your local Paediatric services

Public

Check the patient’s catchment area before requesting assessment. When services are available in the patient’s local area, refer the patient to the local hospital.

Queensland Children’s Hospital

1. Referral can be made by either:

  • GP Smart Referral via BP or Medical Director
  • Secure messaging
    Secure messaging
    Send a written request to the Referral Centre via eReferral
    (Medical Objects ID: RQ402900084, HealthLink ID: qldrchld):

    • To download templates, see Referral Forms.
    • If unable to attach investigations or use secure messaging, fax to 1300 407 281.

    For more information, contact the Referral Centre:
    P.O. Box 3474, South Brisbane QLD 4101
    Phone 1300 762 831
    Fax 1300 407 281

2. Check the minimum referral criteria and insert the required information into referral.

Private

Search for a provider via the National Health Services Directory.

Guideline approval and disclaimer

Guideline approval history
Version no. 1.0 Approval date 01/08/2018 Review date 01/08/2021

Disclaimer

Referral guidelines contain condition-based information for GPs about when to refer a patient, assessment and management measures that should be taken prior to submitting a referral, and what should be included in a referral to the relevant outpatient department or specialist service.
Our referral guidelines aim to help GPs decide which tests and treatments are appropriate for their patients based on their presenting symptoms and previous medical history. Consulting the relevant referral guideline before a patient is referred on to a specialist service may mean that an appointment can be booked sooner and the outcome of their consultation is more conclusive. It can also eliminate the need to refer a patient where preliminary tests rule out the need for specialist intervention.
The information contained within our referral guidelines has been developed in collaboration with specialist medical professionals. They are intended to support referring GPs and are in no way intended to replace their professional medical judgement.

Resources

For health professionals

For families

  • BRAVE-Online – online modules to assist children aged 8 to 12 years to manage anxiety

Contact details

Hospital Switchboard
(Ask for the General Paediatric Registrar)
t: 07 3068 1111

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