Chronic stomach ache in child

Chronic Abdominal Pain in Childhood: Diagnosis and Management

Specific Disease States

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RECURRENT ABDOMINAL PAIN SYNDROME

Recurrent abdominal pain syndrome is a prepubertal functional pain with two distinct peaks of frequency. The first peak occurs between five and seven years of age, with equal frequency in boys and girls and in 5 to 8 percent of children. It is often attributed to the adjustment to parental separation when starting school. The second peak, with a prevalence approaching 25 percent, occurs between eight and 12 years of age and is far more prevalent in girls.6 The pain is vague (identified by the patient’s whole hand at the umbilicus) and is unrelated to meals, activity or stool pattern. Patients are not awakened by the pain. An epigastric location is reported by 10 percent of patients. It is accompanied by autonomic features such as pallor, nausea, dizziness, headache and fatigue. The family history is often positive for functional bowel disease such as irritable bowel syndrome.7 The physical examination is striking for its normality, and the screening laboratory investigations are by definition normal.

The management of recurrent abdominal pain begins with the acknowledgement that the pain is real, that extensive investigations are not warranted and that the child must emphasize normality by remaining in school, continuing activities and resuming a normal diet. Psychologic evaluation and management will be necessary if the degree of incapacity persists. In older children and adolescents, a component of recurrent abdominal pain syndrome is seen in cases of depression or panic disorder with a learned symptomatic conversion reaction and associated weight loss. The performance of laboratory tests with negative results may increase the level of anxiety in older children.

True irritable bowel syndrome occurs infrequently before late adolescence.7 It is best characterized as an intestinal dysmotility with intervals of nuisance diarrhea or constipation. The pain is dull, crampy and located in the left lower quadrant or periumbilical region. As in cases of recurrent abdominal pain syndrome, autonomic features are common. Stress is implicated in the flare-up of symptoms, and a positive family history is common. Management includes dietary factors such as exclusion of contributory lactose intolerance and the addition of fiber to the diet, instruction in stress management techniques and, rarely, the use of antispasmotic medications.

CONSTIPATION

Constipation is a major cause of chronic abdominal pain in children from toddler age to the preteen years. Constipation is best defined as the failure to achieve complete evacuation of the lower colon rather than in terms of infrequency or firmness of stool. The etiology of constipation in most children is an interval of being “too busy” to evacuate completely, producing a dilated lower colon, erratic stool patterns and frequent encopresis. The parents usually do not understand what is causing the child’s discomfort. The child avoids passing the hard stool. The diet is usually high in constipating foods (i.e., cheese, pasta, starches) and low in fiber. The process is usually quite advanced before the family physician is made aware of the problem. Aside from complicating encopresis and bleeding from rectal fissures, symptoms include crampy pain that occurs during large meals and varies greatly in intensity, reduction in appetite and distention of the abdomen (from stool and gas) that occurs in the evening.

The management goal is complete evacuation of the lower colon on a nearly daily basis. This is achieved by whatever means is necessary until muscle tone can be restored over two to six months.8 Initially, a high fiber intake may aggravate the process as a result of increasing bulk in the absence of contractile tone. Therefore, stool softeners such as lactulose (Duphalac) or mineral oil are used first. These are combined with “motivation to go,” which can be achieved in some children with behavior-modification sticker charts but usually requires a stimulant medication such as magnesium hydroxide (Milk of Magnesia) or senna (Senokot). The child is encouraged to establish the “habit” of toilet use with the use of a daily calendar, rewards for attempting defecation and rewards for absence of encopresis. Dietary efforts begin with reducing intake of constipating foods and eventually including increased fiber. Initial management may require use of an enema or suppository, which is repeated only if failure to evacuate exceeds three days. Both softening and stimulant medications are initiated at dosages of one to three teaspoons daily and adjusted to the response of averaging two soft stools a day for six to eight weeks. At that point, most children can tolerate a transition to increased dietary fiber and habitual toilet use.

PEPTIC DISORDERS

The peptic disorders include reflux esophagitis, antral gastritis, gastric and duodenal ulcer, and H. pylori infection. Gastroesophageal reflux in children has recently been reviewed in another article.9

As we mentioned in the section on history, the signs and symptoms of peptic disease include early morning pain, early satiety, night arousal and a positive family history. The pain may be epigastric or periumbilical and is remarkably consistent in character. Occult bleeding is frequent with ulceration and less common in gastritis.10

The major risk factor for peptic ulcer disease in childhood is genetic predisposition: 50 percent of children with duodenal ulcer have a first-degree relative with peptic ulcer disease. The prevalence of duodenal ulcer is two to three times higher in boys than in girls. Gastric ulcer occurs substantially less often than duodenal ulcer, but the prevalence is equal in boys and girls. The approach to peptic management is summarized in Figure 1.

Stress ulcers account for more than 75 percent of peptic disease in infants and young children. Stress ulcers usually present with acute, relatively painless, dramatic upper gastrointestinal bleeding, features shared with gastric ulceration resulting from use of non-steroidal anti-inflammatory drugs (NSAIDs).10 Zollinger-Ellison syndrome with a gastrin-producing tumor is very rare in children; the diagnosis is pursued only in children with multiple ulcers. Acute bleeding is common in children with chronic renal failure, sickle cell disease, cystic fibrosis and cirrhosis.

Antral gastritis is a common peptic presentation in children. Children present with chronic epigastric pain, early satiety with nausea, modest weight loss and a low frequency of family history of peptic disease. Gastric emptying is impaired, and reflux symptoms may be prominent. Results of the stool test for occult blood are usually negative. Radiographic studies are either normal or demonstrate pylorospasm. Many children with antral gastritis have an acute onset of gastritis, often in the context of a viral-like illness.

Endoscopic investigation is generally indicated in the context of active, persistent or recurrent bleeding, with significant morbidity from weight loss, anorexia or chest pain, or for clarification of abnormal findings on radiographic studies. Children with suspected but uncomplicated peptic disease are usually treated with H2 blockers, with endoscopy deferred for pain that persists for more than four weeks, recurrent disease, suspected H. pylori or exclusion of eosinophilic gastritis or enteropathy.4

The medical management of peptic disease is summarized in Table 2. Sucralfate (Carafate), an aluminum sucrose gel, is particularly effective in the treatment of medication-induced gastritis.

TABLE 2

Management of Childhood Peptic Disease

Drug Availability Dosage

H2-receptor blockers

Cimetidine (Tagamet)

300 mg per 5 mL, 200-, 300-, 400-, 800-mg tablets

20 to 40 mg per kg per day, in divided doses every 6 hours

Ranitidine (Zantac)

75 mg per 5 mL, 150-, 300-mg tablets

4 to 8 mg per kg per day, in divided doses every 8 to 12 hours

Nizatidine (Axid)

150-, 300-mg capsules*

4 to 8 mg per kg per day, in divided doses, every 12 hours

Famotidine (Pepcid)

40 mg per 5 mL, 20-, 40-mg tablets

1 to 2 mg per kg per day, once or twice daily, maximum dosage: 40 mg per day

Proton pump inhibitors

Omeprazole (Prilosec)

10-, 20-mg capsules*

0.5 to 3 mg per kg per day, in divided doses every 12 hours

Lansoprazole (Prevacid)

15-, 30-mg capsules*

0.3 to 1.5 mg per kg per day, in divided doses every 12 hours

*—Since no liquid formulations are available at this time, the capsules are opened, and the contents are mixed in an acidic vehicle such as apple juice, applesauce or yogurt.

note: Medication is taken on the schedules given for six to eight weeks, then once daily for four weeks. Diet—Patients should be instructed to eat multiple modest meals and avoid overeating, to minimize caffeine intake and to avoid eating foods that appear to cause pain. Heartburn—To reduce heartburn, patients can be instructed to take an antacid such as Mylanta, Maalox or Milk of Magnesia, in a dosage of 0.5 mL per kg per dose 1 hour after meals and at bedtime, or a low-dose, over-the-counter histamine H2 -blocker such as Tagamet, Pepcid, Zantac or Axid, at one half the usual prescription dosage. Mucosal protection—To enhance mucosal protection, patients can take sucralfate (Carafate) and/or bismuth subsalicylate (Pepto-Bismol) or ranitidine bismuth citrate (Tritec).

TABLE 2

Drug Availability Dosage

H2-receptor blockers

Cimetidine (Tagamet)

300 mg per 5 mL, 200-, 300-, 400-, 800-mg tablets

20 to 40 mg per kg per day, in divided doses every 6 hours

Ranitidine (Zantac)

75 mg per 5 mL, 150-, 300-mg tablets

4 to 8 mg per kg per day, in divided doses every 8 to 12 hours

Nizatidine (Axid)

150-, 300-mg capsules*

4 to 8 mg per kg per day, in divided doses, every 12 hours

Famotidine (Pepcid)

40 mg per 5 mL, 20-, 40-mg tablets

1 to 2 mg per kg per day, once or twice daily, maximum dosage: 40 mg per day

Proton pump inhibitors

Omeprazole (Prilosec)

10-, 20-mg capsules*

0.5 to 3 mg per kg per day, in divided doses every 12 hours

Lansoprazole (Prevacid)

15-, 30-mg capsules*

0.3 to 1.5 mg per kg per day, in divided doses every 12 hours

*—Since no liquid formulations are available at this time, the capsules are opened, and the contents are mixed in an acidic vehicle such as apple juice, applesauce or yogurt.

note: Medication is taken on the schedules given for six to eight weeks, then once daily for four weeks. Diet—Patients should be instructed to eat multiple modest meals and avoid overeating, to minimize caffeine intake and to avoid eating foods that appear to cause pain. Heartburn—To reduce heartburn, patients can be instructed to take an antacid such as Mylanta, Maalox or Milk of Magnesia, in a dosage of 0.5 mL per kg per dose 1 hour after meals and at bedtime, or a low-dose, over-the-counter histamine H2 -blocker such as Tagamet, Pepcid, Zantac or Axid, at one half the usual prescription dosage. Mucosal protection—To enhance mucosal protection, patients can take sucralfate (Carafate) and/or bismuth subsalicylate (Pepto-Bismol) or ranitidine bismuth citrate (Tritec).

The dosages of H2 blockers may seem high, especially since medication is usually given three times daily during the first two weeks of therapy, but acid secretion in children reaches adult levels by the age of four months.10 Regrettably, none of the medications employed for peptic disease have been approved by the U.S. Food and Drug Administration for use in children, and family physicians who are not familiar with pediatric peptic management are encouraged to coordinate care with a pediatric gastroenterologist.

Proton pump inhibitors are generally employed only after endoscopic biopsy confirmation of failure to respond to H2 blocker therapy. Until additional information is available about the safety of long-term use, proton pump inhibitors are usually prescribed for intervals of two to four months.11

In 1984, Marshall and Warren12 demonstrated the role of a gram-negative aerophilic bacterium, H. pylori, in chronic gastritis and peptic ulcer disease in adults. Drumm and colleagues13 quickly confirmed the role of Helicobacter in chronic antral gastritis in children. This bacterium produces a cytotoxin, urease, mucinase and superoxide dysmutase, which act in concert to produce gastric and/or duodenal injury. Exposure to the bacterium, as measured by antibody production, increases throughout childhood in the United States, reaching 11 percent by five years of age, 20 percent by 10 years of age and 45 percent by the late teens.14 Since this rate of seroconversion is far in excess of the rate of documented peptic disease, the significance of an isolated positive serologic test result is unknown.

The best described clinical syndrome in childhood is antral gastritis, which features early satiety, epigastric abdominal pain and nodular antral gastritis on endoscopy. Studies addressing the role of Helicobacter in less peptic conditions such as recurrent abdominal pain syndrome have been inconclusive to date.15 Recognizing the limitations of a positive serology result and the research status of the C-13–urease breath test, the diagnosis in children has been dependent on documentation of the bacterium in endoscopic biopsies of the stomach and duodenum. Most children receive quadruple therapy with continued acid suppression combined with a two- to three-week course of amoxicillin or clarithromycin (Biaxin), metronidazole (Flagyl) and bismuth subsalicylate (Pepto-Bismol).16 This treatment regimen is successful in approximately 90 percent of patients. Endoscopic confirmation of healing is indicated with recurrent or persistent symptoms. Antibiotic resistance is an increasing concern, so empiric treatment for possible Helicobacter infection is discouraged.

PERIODIC SYNDROME OR CYCLIC VOMITING/ABDOMINAL MIGRAINE

Gee’s original description of a syndrome with “fits of vomiting … with disease-free intervals” in 1882 has held up well in the clinical definition of periodic syndrome, which is now called cyclic vomiting syndrome or abdominal migraine of childhood.17 Children present with episodic nausea, abdominal pain and usually significant emesis, typically beginning during the night or early morning hours and lasting from six to 48 hours, with intervening intervals of weeks to months with no symptoms or findings at all. The majority of children have a family history of migraine and may have other autonomic features such as pallor, explosive diarrhea, lethargy and tachycardia. Of note, headache is rare in children with cyclic vomiting syndrome, although it may evolve into more classic migraine in adolescence. Treatment is usually early intervention with anti-emetics or migraine medications.

INFLAMMATORY BOWEL DISEASE

Abdominal pain is frequently reported in children with ulcerative colitis and Crohn’s disease. The pain, which typically occurs in the lower abdomen, is cramping in nature and increases after meals or activity. The pain is reduced by eating smaller meals, which contributes to the anorexia and growth impairment that occur in children with inflammatory bowel disease. The diagnosis is relatively easy when the child has bloody diarrhea, the need to defecate during the night, perianal disease or an ileal mass on abdominal examination. More subtle features include delayed puberty, anemia that is unresponsive to iron therapy, recurring oral aphthous ulcers, chronic liver disease, or large joint synovitis or arthritis.18 The diagnosis is established by small bowel barium contrast x-ray and colonoscopy with biopsies. The management of inflammatory bowel disease in childhood is summarized in Table 3.19

TABLE 3

Management of Inflammatory Bowel Disease in Children

Supportive care for child and family

Provide educational materials for child, parents, teachers

Give information about support groups for children and parents

Offer psychologic counseling for depression, denial and noncompliance

Expect reactive self-manipulation of medication dosages and diet

Nutritional support

Correct deficits of macronutrients and micronutrients

Deliver 125 percent of calories for height age

Recommend routine multivitamin and mineral supplements

Discourage “quick cure” diets and fads

Administer intravenous nutrition to patients with intractable Crohn’s disease or fistula and before surgery

Consider consumption of an elemental diet as primary therapy in patients with small bowel Crohn’s disease

Anti-inflammatory/immunomodulatory medication

Prednisone (oral, intravenous, topical enema)

Valuable in all forms, but use must be balanced against side effects

Useful as chronic alternate-day therapy in adolescent patients with Crohn’s disease

Salicylates: sulfasalazine (Azulfidine), mesalamine (Asacol, Pentasa, Rowasa), aminosalycylic acid (Paser Granules)

Valuable in treating mild to moderate colitis

Metronidazole (Flagyl; possibly ciprofloxacin as well in older children)

Useful in treating Crohn’s perianal or fistula disease

Also useful in treatment of complicating Clostridium dificile infection

Azathioprine (Imuran)/6-mercaptopurine (Purinethol)

Valuable in treating moderate to severe Crohn’s colitis, ulcerative colitis

Fish oil (EPA, Sea Omega, Promega)

Valuable in treating mild ulcerative colitis

Surgical resection

Total colectomy is curative in cases of ulcerative colitis

Useful in cases of toxic megacolon, and dysplasia in patients with ulcerative colitis

Useful in treating Crohn’s obstruction, fistula, abscess

Useful when medical therapy fails or side effects of medication are intolerable

Information from O’Gorman M, Lake AM. Chronic inflammatory bowel disease in childhood. Pediatr Rev 1993;14:475–80.

TABLE 3

Supportive care for child and family

Provide educational materials for child, parents, teachers

Give information about support groups for children and parents

Offer psychologic counseling for depression, denial and noncompliance

Expect reactive self-manipulation of medication dosages and diet

Nutritional support

Correct deficits of macronutrients and micronutrients

Deliver 125 percent of calories for height age

Recommend routine multivitamin and mineral supplements

Discourage “quick cure” diets and fads

Administer intravenous nutrition to patients with intractable Crohn’s disease or fistula and before surgery

Consider consumption of an elemental diet as primary therapy in patients with small bowel Crohn’s disease

Anti-inflammatory/immunomodulatory medication

Prednisone (oral, intravenous, topical enema)

Valuable in all forms, but use must be balanced against side effects

Useful as chronic alternate-day therapy in adolescent patients with Crohn’s disease

Salicylates: sulfasalazine (Azulfidine), mesalamine (Asacol, Pentasa, Rowasa), aminosalycylic acid (Paser Granules)

Valuable in treating mild to moderate colitis

Metronidazole (Flagyl; possibly ciprofloxacin as well in older children)

Useful in treating Crohn’s perianal or fistula disease

Also useful in treatment of complicating Clostridium dificile infection

Azathioprine (Imuran)/6-mercaptopurine (Purinethol)

Valuable in treating moderate to severe Crohn’s colitis, ulcerative colitis

Fish oil (EPA, Sea Omega, Promega)

Valuable in treating mild ulcerative colitis

Surgical resection

Total colectomy is curative in cases of ulcerative colitis

Useful in cases of toxic megacolon, and dysplasia in patients with ulcerative colitis

Useful in treating Crohn’s obstruction, fistula, abscess

Useful when medical therapy fails or side effects of medication are intolerable

Information from O’Gorman M, Lake AM. Chronic inflammatory bowel disease in childhood. Pediatr Rev 1993;14:475–80.

Mom, My Belly Hurts: Common Digestive Issues in Children

Hearing “my tummy hurts” from a youngster can strike fear in the heart of a parent.

Stomachaches, though, are a common complaint among children, and most are completely normal: they usually suggest that a child ate too much or needs to go to the bathroom. But how do you know when tummy troubles signal something more serious?

Here’s how to evaluate the severity of your child’s stomachaches.

When Stomachaches Interfere With Life

Frequent or chronic stomachaches could indicate that something in the digestive system needs medical attention. Keep in mind that children might say that their stomach hurts when the the pain actually originates in a nearby organ, like the appendix.

If your child’s bellyaches start to interfere with daily life — hindering school attendance or participation in events like birthdays or soccer games —, they may be worth a trip to the doctor’s office. “It doesn’t necessarily signal disease, but it does signal that they need to seek medical care,” said Craig Friesen, MD, division director of gastroenterology and medical director of the abdominal pain program at Children’s Mercy Hospital in Kansas City and a professor of pediatrics at the University of Missouri-Kansas City School of Medicine.

The challenge is different in younger kids. A little girl may say her tummy hurts, but what she’s really saying is that she has a bowel movement and needs to use the toilet. “Most of what I do with toddlers is tell them to go to bathroom and, if it still hurts, to go play,” Friesen said. “If they don’t do either, then the child needs to be evaluated.”

The Most Common Signs to Look For

Children younger than 8 may not be able to differentiate between stomach pain and the kind of pain that warrant urgent medical attention, Friesen said. “I ask them to point to where the pain is worst,” he said. “If they point to the lower right, they may need to go to the ER for appendicitis.” So if your child’s pain persists, you should try to keep track of new and existing symptoms.

Some of the indicators that a child’s stomachache might be serious include weight loss, fever, significant vomiting, severe diarrhea, blood in the stool or vomit, or pain in the upper right or lower right abdomen. If a child has any of these symptoms, seek medical attention as soon as possible.

What Causes Digestive Issues in Kids

If the pain is in the upper right abdomen, gallbladder disease, although rare in children, could be the problem. Friesen said more common causes are colitis (inflammation of the large intestine) or irritation in the first part of the small intestine.

When a child’s ache is below the belly button, Friesen said, the most common causes are irritable bowel syndrome (IBS), constipation, colitis, or an allergic reaction. In about nine out of 10 cases, IBS or functional dyspepsia (indigestion without a known cause) are the disorders behind the pain.

IBS symptoms, such as loose and more frequent bowel movements, often occur after eating and may be treated with dietary changes, medications, or probiotics. Functional dyspepsia can cause ulcer-like symptoms like nausea, vomiting, filling up easily, and bloating. Treatments include acid-reducing drugs, which tends to work well in children.

Celiac disease is another issue that children may suffer from. It causes a lifelong intolerance to gluten — found in wheat, barley, rye, and some oats — and can cause abdominal pain, bloating, and loose or hard stools. A dietary change is usually enough to treat it.

Lactose intolerance makes it difficult for the body to efficiently process lactose, the sugar found in milk and other dairy products, and can therefore prompt stomachaches.

While both conditions aren’t as common among children, Friesen said that lactose intolerance emerges at different ages, mainly because of genetic differences. African-American children, for instance, tend to develop allergic reaction to dairy between the age of 3 and 5, while Caucasian children usually contract it when they are 8 or 10 years old.

Finally, recurrent abdominal pain in children is increasingly recognized as an initial sign of migraine headaches. Five to 15 percent of children with recurrent abdominal pain that isn’t attributable to any other source may be subject to migraines.

Though most tummy woes are likely to pass, recognizing some of the most worrisome signs and knowing when to call the doctor will make both you and your child feel better, sooner.

Common Stomach & Intestinal Problems in Children and Adolescents

Children’s abdominal complaints have many potential causes, most of which are not dangerous, but some (such as appendicitis) can be life threatening. For this reason, all belly problems should be monitored closely and treated with care. To help parents determine the best course of action when their child has abdominal upset, I’ve summarized the most common causes of stomach and intestinal concerns in children and adolescents, as well as their treatments. At the end I’ll review some “red flags” that should trigger parents to seek medical attention.

Heartburn (Reflux Disease)

Heartburn symptoms are fairly common in children and adolescents, with as many as 3 to 5 percent of all adolescents experiencing reflux disease. Chest and upper abdominal discomfort occurs when acidic stomach contents slide upwards into the esophagus, causing irritation and a burning sensation. Reflux is caused by decreased strength of the valve (esophageal sphincter) that closes the esophagus off from the stomach or from obesity (which increases stomach pressure). Diet can also play a role in triggering episodes of heartburn.

Treatments for Reflux Disease

If your child is prone to reflux symptoms, there are several things you can do to reduce the frequency of their problems before resorting to medication. For example, if certain foods seem to trigger heartburn (such as acidic or fatty foods), then avoiding those consistently is a good first step. Be aware that the position of the body can greatly influence the likelihood of regurgitation. Encourage your child not to eat before bedtime or lie down after a large meal. Elevating the head of your child’s bed can also decrease the flow of stomach contents into the esophagus. If your child is overweight or obese, losing weight may resolve his or her reflux problems.

If these lifestyle interventions do not control your child’s heartburn, there are three kinds of over-the-counter (OTC) medications that may be helpful. They each treat heartburn in a different way, so be sure to find the one(s) that works best. In some cases, relief may be achieved by using more than one medicine at a time. Always make sure that you read the Drug Facts label carefully before offering any medicine to your child or teen.

  1. Antacids – work by neutralizing the acidic properties of stomach contents so that they cause less irritation if they escape the confines of its tough lining. The active ingredients in antacids include aluminum hydroxide and magnesium hydroxide (to be used in children aged 12 and over) and calcium carbonate (approved for use in children aged 2 and over).
  2. Histamine Receptor (H2) Blockers – work by preventing the stomach from producing acid. Active ingredients in H2 blockers include: cimetidine, ranitidine, famotidine and nizatidine. These medicines are indicated for children 12 and older; ask a doctor about treating children under 12.
  3. Proton Pump Inhibitors – these medicines are not available for children under 18, and the OTC labels are only for use by adults. They work to reduce stomach acidity by blocking tiny acid pumps on the stomach lining wall. Active ingredients in PPIs include: omeprazole, omeprazole with sodium bicarbonate, and lansoprazole.

Constipation

Constipation is a very common problem, and accounts for 3 to 5 percent of all pediatrician visits. Although people often think of constipation as synonymous with hard stool, the medical definition of constipation is more specific and must include two or more of the following symptoms (occurring at least once a week for two months) in a child older than four years of age:

  • Two or fewer defecations per week
  • At least one episode of fecal incontinence per week
  • History of retentive posturing or excessive volitional stool retention
  • History of painful or hard bowel movements
  • Presence of a large fecal mass in the rectum
  • History of large-diameter stools that may obstruct the toilet

Constipation may be caused by a low fiber diet, painful defecation (causing the child to avoid passing stool), food intolerances, medications and bowel dysfunction (related to different diseases).

Lifestyle treatments that may be helpful in remedying constipation include: regular exercise, increased fluid consumption, higher fiber diet, discontinuing cow’s milk and behavior modification (such as toilet breaks at regular intervals).

OTC treatments that are commonly used to treat constipation include: Stool softeners, laxatives (four types), enemas, and suppositories.

  1. Stool softeners – prevent stool from becoming too hard by introducing a slippery substance into the stool while it’s being formed. The active ingredient in stool softeners is docusate. Ask a doctor for advice on treating children under 2.
  2. Laxatives:
    • Osmotic laxatives – draw water into the bowel from other body tissues to make stool more moist. For children, the most commonly used laxatives include polyethylene glycol, magnesium citrate hydroxide, and lactulose. Ask a doctor for advice on treating children under 17.
    • Lubricant laxatives – coat the stool with an oily layer to keep it from drying out. Mineral oil is the most common example of a lubricant laxative and can be used orally or rectally. Ask a doctor for advice on treating children under 6.
    • Stimulant laxatives – stimulate the bowel to increase its contractions, moving stool through the intestines faster. Senna (a derivative of tree bark) and bisacodyl are used in cases of more severe childhood constipation. Ask a doctor for advice on treating children under 6.
    • Bulk-formers (fiber) – Bulk-forming laxatives absorb liquid in the intestines and swell to form a soft, bulky stool. The bowel is then stimulated normally by the presence of the bulky mass. Some bulk-forming laxatives ingredients are psyllium (ask a doctor for children under 6) and polycarbophil (ask a doctor for children under 3).
  3. Enemas and suppositories flush stool from the bowel (enemas) or stimulate the bowel to contract (suppositories). The most common active ingredients used in enemas and suppositories for severely constipated children or adolescents include: mineral oil enemas (under 2 do not use), saline enemas (under 2 do not use) and bisacodyl suppositories. Ask a doctor about treating children under 6.

Red Flag Review

Although most cases of heartburn, constipation, and diarrhea are not dangerous, it is important to be on the lookout for more concerning signs and symptoms that could require immediate medical attention. These include:

  • Severe abdominal pain. This could be caused by life-threatening medical conditions such as appendicitis. Call your healthcare provider right away if your child has extreme abdominal pain.
  • Blood in vomit. Especially larger amounts. Please check out this helpful first-aid guide for managing vomiting in children.
  • Blood in stool. Blood can be bright red to black in appearance.
  • Dangerous dehydration. May include high fevers lasting many days, a large amount of diarrhea, fast heart rate, dizziness with standing, decreased skin turgor (tone, firmness), dry mouth, decreased urine output, lack of tears, unusually deep breathing, lethargy and/or irritability.
  • Risk of a toxic ingestion. If you think that your child may have consumed a toxic household substance, call the Poison Control Center hotline immediately: 1-800-222-1222.

The 5 Most Common Digestive Disorders in Kids

  • 1

    Digestive disorders can disrupt a child’s growth and development—and make life uncomfortable for you and your child. But how can you tell the difference between passing tummy trouble and a disturbing digestive disorder? By recognizing the symptoms of these five most common digestive conditions in children, you can help your child find effective treatment and enjoy a safe, healthy diet.

    More Than Tummy Trouble https://d33ljpvc0tflz5.cloudfront.net/dims3/MMH/crop/5387×3604%2B0%2B0/resize/580×388/quality/75/?url=https%3A%2F%2Fd26ua9paks4zq.cloudfront.net%2F2c%2Ffc%2Fafd15c1e433b9f17b8ee0f4d092a%2Fimage-getty-522902802.jpg

  • 2

    What it is: It’s perfectly normal for babies to spit up many times per day in the first few months of life. But if your baby is also irritable and has difficulty eating, your child might have GERD, a condition in which stomach acid backs up and irritates the esophagus, the tube leading from the mouth to the stomach.
    Number of children affected: Two-thirds of four-month-old babies have symptoms of GERD. By age one, about 10% of infants have GERD.

    1. Gastroesophageal Reflux Disease (GERD) https://d33ljpvc0tflz5.cloudfront.net/dims3/MMH/thumbnail/580×388/quality/75/?url=https%3A%2F%2Fd26ua9paks4zq.cloudfront.net%2Fa0%2F9a%2F71b905e94709a616c1f85198e756%2Fresizes%2F1500%2Fimage-getty-478169271.jpg

  • 3

    Simple tweaks in feeding routine can make all the difference for babies with GERD. Avoid overfeeding; if your baby stops nursing or drinking from the bottle, don’t encourage more. Keep your baby upright for half an hour after feeding, but avoid placing your baby in a car seat when not in a moving vehicle. The semi-reclined position in the car seat can promote reflux. Prescription medication can help, but is rarely necessary. Most children outgrow GERD.

    How to Help Kids With GERD https://d33ljpvc0tflz5.cloudfront.net/dims3/MMH/thumbnail/580×388/quality/75/?url=https%3A%2F%2Fd26ua9paks4zq.cloudfront.net%2Fd0%2F84%2F0ec7a3944a4d8d902ad4b806d9cd%2Fimage-getty-177182990.jpg

  • 4

    What it is: Celiac disease is an intolerance to gluten, a protein found in wheat, rye and barley. When people with celiac disease eat gluten-containing foods, their immune system attacks and damages the lining of the small intestine.
    Number of children affected: Approximately 1 in 133 Americans has celiac disease. Children whose parents, siblings, aunts or uncles have celiac disease are most likely to have the condition.

    2. Celiac Disease https://d33ljpvc0tflz5.cloudfront.net/dims3/MMH/thumbnail/580×388/quality/75/?url=https%3A%2F%2Fd26ua9paks4zq.cloudfront.net%2F9a%2Fa6%2Fa7d0192d4e0ead2d5bc6c65f3a8d%2F12-myths-about-gluten-13.jpg

  • 5

    Celiac disease can be an invisible disease; more than half of all affected children do not have any symptoms. Children who do experience symptoms might not be diagnosed because the signs—stomach pain, gas, diarrhea—are incredibly common. Bring any unusual digestive symptoms to your pediatrician’s attention, particularly if your child has a family history of celiac disease, is losing weight, or is failing to grow. Your doctor can run tests to check for celiac disease. The only treatment for celiac disease is a gluten-free diet.

    How to Help Kids With Celiac Disease https://d33ljpvc0tflz5.cloudfront.net/dims3/MMH/crop/1494×999%2B0%2B0/resize/580×388/quality/75/?url=https%3A%2F%2Fd26ua9paks4zq.cloudfront.net%2F96%2Ff8%2Ff47a96af42799d434e3add0b04eb%2Fresizes%2F1500%2Fimage-gettyimages-548563715-child-eating-apple-with-father.jpg

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    What it is: Inflammatory bowel disease is an inflammation of the digestive tract. Ulcerative colitis and Crohn’s disease are both types of inflammatory bowel disease. Symptoms include diarrhea, blood in the stools, and abdominal pain.
    Number of children affected: More than 1.6 million Americans have IBD. About 10% of those diagnosed are under the age of 18.

    3. Inflammatory Bowel Disease (IBD) https://d33ljpvc0tflz5.cloudfront.net/dims3/MMH/crop/1491×997%2B0%2B0/resize/580×388/quality/75/?url=https%3A%2F%2Fd26ua9paks4zq.cloudfront.net%2F82%2F46%2F51558dbc40ef86c2f69c89fb4dbb%2Fresizes%2F1500%2Fimage-gettyimages-135538334-mother-caring-for-sick-child.jpg

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    Proper diagnosis is key to effective treatment. Your child’s doctor may order blood tests, X-rays and other imaging scans to pinpoint the source of your child’s discomfort. Medication can ease the symptoms of IBD and improve digestion. Some of these medications suppress the immune system, so talk to your healthcare provider about ways to keep your child healthy. Good nutrition is important too. Serve easy-to-eat, nutrient dense foods, such as bananas, whole-wheat pasta and eggs. During flare-ups, avoid nuts and seeds, which can irritate the intestine.

    How to Help Kids With IBD https://d33ljpvc0tflz5.cloudfront.net/dims3/MMH/crop/1496×1001%2B0%2B0/resize/580×388/quality/75/?url=https%3A%2F%2Fd26ua9paks4zq.cloudfront.net%2Fca%2F19%2Fa234d967417e9662116b44236754%2Fresizes%2F1500%2Fimage-gettyimages-533768737-doctor-speaking-with-mother-and-child.jpg

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    What it is: Lactose is a naturally occurring sugar in milk. People who are lactose-intolerant lack the enzyme needed to break down this sugar, so they can’t digest it. Symptoms include diarrhea, stomach cramps, and gas or bloating after eating dairy products.
    Number of children affected: It’s difficult to say. Almost all human babies can digest lactose at birth. By age 20, about 30 million Americans have some degree of lactose intolerance.

    4. Lactose Intolerance https://d33ljpvc0tflz5.cloudfront.net/dims3/MMH/crop/4352×2911%2B0%2B0/resize/580×388/quality/75/?url=https%3A%2F%2Fd26ua9paks4zq.cloudfront.net%2F98%2Fb5%2F4cb55b5c4ba0917d613187486484%2Fimage-getty-155437659.jpg

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    If your child experiences discomfort eating dairy, try holding off on all milk-based products for a while and see how he feels. The good news is a child with lactose intolerance may not have to avoid dairy forever. Some people find they can handle small amounts of milk, ice cream or cheese, particularly if eaten with other food. Another option: enzyme supplements, such as Lactaid tablets. These pills contain the enzyme needed to help your child break down lactose in food, and can be taken as needed.

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    What it is: Inflammation of the esophagus, the tube leading from the mouth to the stomach, caused by a collection of white blood cells called eosinophils. Eosinophilic esophagitis can cause difficulty swallowing, pain, nausea and vomiting.
    Number of children affected: Approximately 1 in 10,000. Nearly three-quarters of those affected are white males.

    5. Eosinophilic Esophagitis https://d33ljpvc0tflz5.cloudfront.net/dims3/MMH/thumbnail/580×388/quality/75/?url=https%3A%2F%2Fd26ua9paks4zq.cloudfront.net%2Ffa%2Ff6%2F3e7f5e6f401a9b351f1d4bf13fa4%2Fresizes%2F1500%2Fimage-getty-107806177.jpg

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    Eosinophilic esophagitis is often caused by a food allergy, so your child’s doctor may recommend allergy testing and an elimination diet. During an elimination diet, you remove all likely irritants from your child’s diet, including common allergy-causing foods such as milk, eggs, nuts, beef, wheat, fish, shellfish, corn and soy. These foods are added back in gradually, one at a time, while you carefully watch for the recurrence of symptoms. Once your child’s triggers have been identified, avoid those foods and you should see symptoms improve.

    How to Help Kids With Eosinophilic Esophagitis https://d33ljpvc0tflz5.cloudfront.net/dims3/MMH/thumbnail/580×388/quality/75/?url=https%3A%2F%2Fd26ua9paks4zq.cloudfront.net%2F35%2F97%2F519a63b1448ea9bad187441b148c%2Fresizes%2F1500%2Fimage-getty-147059167.jpg

Hirschsprung Disease

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What Is Hirschsprung Disease?

Hirschsprung (HERSH-sproong) disease affects the large intestine (colon) of newborns, babies, and toddlers. It makes them have trouble emptying their bowels. Most of the time, the problems with pooping start at birth, although in milder cases symptoms may appear months or years later.

Treatment almost always requires surgery. Fortunately, most children who have surgery are fully cured and able to pass bowel movements (BMs) normally.

Hirschsprung disease can cause constipation, diarrhea, and vomiting. Sometimes it leads to serious colon complications, like enterocolitis and toxic megacolon, which can be life-threatening. So it’s important to diagnose and treat Hirschsprung disease as early as possible.

What Are the Signs & Symptoms of Hirschsprung Disease?

The symptoms of Hirschsprung disease can vary depending on how severe it is. Children with severe cases usually will have symptoms within the first few days of life.

Newborns with Hirschsprung disease may:

  • be unable to pass stool within the first or second day of life
  • have a swollen belly, bloating, or gas
  • have diarrhea
  • vomit (which may look green or brown)

A newborn who can’t poop within the first 48 hours of life is often how doctors find Hirschsprung disease. This red flag can be very valuable in diagnosing the condition.

Less severe cases might not be spotted until a child is a little older, or sometimes even later. Symptoms in these cases are usually milder but can be long-lasting (or

). They can include:

  • a swollen belly
  • constipation
  • trouble gaining weight
  • vomiting
  • gas

Older kids with Hirschsprung disease might have a growth delay because the condition can affect the body’s ability to absorb nutrients.

What Causes Hirschsprung Disease?

Hirschsprung disease prevents bowel movements (stool) from passing through the intestines due to missing nerve cells in the lower part of the colon. It’s caused by a birth defect.

Normally, the large intestine moves digested material through the gut by a series of contractions called peristalsis. This is controlled by nerves between the layers of muscle tissue in the intestine.

Children who have Hirschsprung disease are missing those nerves along part of the length of their colons. This prevents the colon from relaxing, which can cause a blockage of digested material and make it hard for poop to pass.

When Hirschsprung disease affects the entire large intestine, it’s called long-segment disease. When it affects a shorter length of the colon closer to the rectum, it’s called short-segment disease. It’s more common for nerve cells to stop developing closer to the rectum. That’s because in the womb, an unborn baby’s cells develop on a pathway that starts at the top of the large intestine and ends near the rectum. In Hirschsprung disease, nerve cells stop developing while on that pathway.

Who Gets Hirschsprung Disease?

Doctors aren’t sure why some children get Hirschsprung disease. But they do know it can run in families. It also affects boys more often than girls. Children with Down syndrome and genetic heart conditions also have an increased risk of Hirschsprung disease.

How Is Hirschsprung Disease Diagnosed?

To diagnose Hirschsprung disease, doctors often do a test called a barium enema. Barium is a dye put into the colon using an enema. The barium shows up well on X-rays and can help doctors get a clearer picture of the colon. (In kids with Hirschsprung disease, the intestine usually appears too narrow where the nerve cells are missing.)

In some cases, the doctor might do a rectal suction biopsy. This test, which can often be done in the office, involves using a suction device to remove some cells from the colon’s mucous lining. This test will show if nerve cells are missing.

For older kids, doctors may use different tests, such as manometry or a surgical biopsy. Manometry is a test in which a balloon is inflated inside the rectum to see if the anal muscle relaxes as a result. If the muscle doesn’t relax, the child may have Hirschsprung disease. In a surgical biopsy, the doctor removes a sample of tissue from the colon to examine under a microscope.

How Is Hirschsprung Disease Treated?

Surgery is thought to be the most effective treatment for Hirschsprung disease. This is done in one step or two, depending on how severe it is. Children who are very sick at the time of surgery (from an inflamed colon or poor nutrition) may need to undergo surgery in two steps.

The most common surgery to correct Hirschsprung disease involves removing the section of the colon without nerves and reattaching the remaining section to the rectum. Often, this can be done in one step through minimally invasive (laparoscopic) surgery right after the condition is diagnosed.

In some cases, the doctor may do the surgery in two steps.

In the first surgery:

  • The doctor will remove the unhealthy section of the colon. Then, in a procedure called an ostomy, the doctor creates a small hole, or stoma, in the child’s abdomen and attaches the upper, healthy section of the colon to the hole.

The two types of ostomy are:

  1. Ileostomy: removing the entire large intestine and connecting the small intestine to the stoma
  2. Colostomy: removing just a section of the colon

The child’s stool passes through the stoma into a bag that is connected to it, which needs to be emptied several times a day. This allows the lower part of the colon to heal before the second surgery.

In the second surgery:

  • The doctor closes the hole and attaches the normal section of the colon to the rectum.

What Happens After Surgery?

After surgery, kids often get constipated. Laxatives can offer some relief, but check with your doctor about which would be best for your child.

For children old enough to eat solid foods, a high-fiber diet can ease and prevent constipation. Drinking plenty of water is also important, and helps prevent dehydration. The large intestine helps absorb water from food, so dehydration can be a concern for children who have had part of their intestine removed.

Kids who still have symptoms or get new ones after surgery (such as explosive and watery diarrhea, fever, a swollen belly, or bleeding from the rectum) should have medical attention right away. These can be signs of enterocolitis, an inflammation of the intestines.

Looking Ahead

Most children treated surgically for Hirschsprung disease have an excellent outcome. Most can pass stool normally and have no lasting complications. A few kids might continue to have symptoms, including constipation and bowel control problems.

Reviewed by: Jolanda M. Denham, MD Date reviewed: July 2018

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