What belly aches need to go to the Emergency Department?

The Pediatric Insider

© 2014 Roy Benaroch, MD

Giving advice over the phone is always tricky. I can’t see your child, I can’t see the chart, and I can’t get a detailed history or any physical exam at all. After-hours calls aren’t really to make diagnoses or give detailed medical advice—they’re really just for me to try to make sure your child is safe to wait until the next day to see us in the office. If not, it’s off to the Emergency Department. Believe me, as long as it’s safe, I’d really like to keep you away from there.

One of the most common “do I need to go to the ED?” calls are about belly pain. Kids get a lot of belly aches, from all kinds of things, and obviously most of them don’t require emergency care. Except those that do: appendicitis tops the list, but also bowel obstructions or ovarian torsion or a handful of other things that really can’t wait until the next day. So how can I know, over the phone, if you really do need to take your child to the emergency department?

Disclaimer: I haven’t talked to you, and I’m not your kid’s doctor, and I’m not giving you specific medical advice here. If you’re thinking your child has a bad belly ache, call your own doctor for specific medical advice. Stop looking things up on the internet—there are too many weirdos out there giving out poor information, and you’re wasting your time. Go pick up your phone and call your own doctor, now. And thanks for visiting my blog!

These are the questions I ask, things I’ve found can help distinguish which belly aches need immediate evaluation:

How does your child look, overall? A child who’s very pale or grey or barely moving needs to go to the ED. If he says it hurts but he’s walking around and looks pretty good, it can probably wait.

If the belly actually tender? Tender means “hurts to touch.” I’ll ask parents over the phone to gently squeeze the belly, here and there. Don’t ask your child if it hurts, just watch his face—if he grimaces in pain or pushes your hand away, the belly is tender. That means: to the ED.

What other symptoms are there? Frequent or forceful vomiting is concerning, especially if there’s yellow or green tint from bile. Really, any combination of serious symptoms along with belly pain are likely to lead to an ED referral.

How long has this been going on? Belly aches that have been going on for many days or weeks or months are much less likely to be an emergency than belly aches that just started, or are intensely worsening over a few hours.

Where does it hurt? Belly aches in the center of the abdomen, near the belly button, are less likely to be caused by something that needs urgent attention than belly pain in the corners, away from the center.

There’s more to phone medicine than these questions, but that’s a pretty good start. Again, if you’re worried, call your own doctor for specific advice about your own child. Most belly aches can be safely managed at home, but every once in a while there’s a serious emergency brewing. Give your doc a call with the answers in mind to these questions, and you’ll be able to get better advice to make sure your child is OK.

School morning belly aches: Are they “real”?

The Pediatric Insider

© 2012 Roy Benaroch, MD

Dave’s story: “I have a six year old who gets a lot of belly aches. She’s seen her ped and a GI, and all the tests say nothing. Her belly aches really only happen in the morning before school. I think it might be psychological, and have told her about the boy who cries wolf, but she insists that her tummy hurts. What should we do?”

We need to settle one thing up front. These belly aches are in every sense “real”, even if they’re related to psychological factors on school days. The pain is real, because the pain hurts. Telling her that it doesn’t hurt, or talking with her about boys and wolves, is unlikely to help her feel better.

There’s this weird, false dichotomy in medicine between “real” and “not real” in the way we talk about medical problems—as if psychiatric or psychological issues are less important in some way. Sometimes words like “organic” are used for “real” pathology, as opposed to “inorganic”, whatever that means. You’ll also see references to “functional” pain, somehow implying that this kind of pain is somehow less real. But it still hurts!

There’s even a specific name for “GI pain where no pathology can be seen through a microscope and no lab tests are abnormal but nonetheless it hurts and ow I wish it would feel better.” It’s called irritable bowel syndrome, and it affects millions. Again: it hurts.

Dave’s already taken an important step: by keeping track of the symptoms, he’s narrowed this down to a school-morning phenomenon. That’s very important information, because it tells us that we don’t need more invasive tests or procedures. Instead, we ought to be focusing on ways to help the child feel better. Is there a specific stressor (like a bully) at school? Can we reduce overall stress in other ways? Can we think of ways to make school mornings a little less dread-inducing? Perhaps, in addition to reducing stress, we can also start to teach the child new ways of dealing with stress—like a special lovey to hug, or a punching bag to whale on (you can see, the approach may depend on the child!) Things like a hot water bottle, extra time on the toilet, or waking up early enough so the family doesn’t have to rush can all help.

The bottom line: belly aches that only happen on school day mornings are real. Parents won’t be able to talk their child out of it. Instead, we ought to be working with our children to see how we can help them feel better.

Constipation remedies

The Pediatric Insider

© 2012 Roy Benaroch, MD

Li wrote: “I saw an article you posted about potential causes for excessive urination for children.  One of the mentioned problems involved constipation.  Do you have any advice on where I can find more info on ways to relieve this problem through diet?  I was told build up of old stool is the cause of my child’s urinary problems.”

Constipation is very common, and it can lead to urinary problems like frequent urination, wetting, and painful urination. It’s no fun to be constipated, and I think parents need to treat this aggressively. Untreated constipation leads to harder, even-more-painful stools, which leads to more stool holding, which leads to worsening constipation. It’s what I sometimes dramatically call the Constipation Death Spiral—it gets worse and worse until it’s treated correctly and consistently. Fortunately, all but the most severely constipated kids can be treated with a few simple steps.

What is constipation? Normal stools might be anywhere from three times a day to once every three days—so it’s not really a matter of how often kids go. It’s what it feels like. Stool that’s firm enough or large enough to be uncomfortable is a sign of constipation. If it hurts, it’s constipated. If Junior is holding it in because it hurts, that’s worse constipation. If Junior has gotten so used to holding it that he doesn’t even realize he’s full of stool that leaks sometimes, that’s really bad constipation.

Some kids with significant constipation don’t really complain of pain much. They might have an occasional belly ache (especially after eating), or might only have urinary symptoms or stool leakage.

Why is constipation so common? I believe it comes down to diet. Our guts developed through almost all of human history to digest minimally processed foods. Even people who pursue a very “healthy” diet these days are still eating in a way that dramatically different from what our ancestors ate for thousands of years. It’s not all bad—human nutrition, at least in the developed world, has never been better. For the first time in history we suffer more now from overnutrition than from undernutrition. Still, one cost of all of this abundant, easy-to-eat-and-digest food is chronic constipation.

The first rule of treating constipation is to treat it. Do what it takes to fix it, and keep it fixed, for long enough that new patterns develop and children forget that they used to be afraid of their painful stools. Often parents make half-hearted attempts for a week or so, then give up as things maybe start to improve a little. Take my word for it: if you want to get out of the constipation spiral, you need to be consistent, and you need to be in it for the long haul.

The second rule is to try to avoid relying on enemas or suppositories. Your children do not want you anywhere near their anus. Constipation can almost always be treated orally. If you’re needing to go from the back route, you ought to be doing so while working with a doctor (though, hopefully, not in the same room.)

What can you do to treat constipation? Start by setting up a time, usually after a big meal, where your child is expected to sit on the pot for a set amount of time. The bathroom break isn’t until the child thinks his business is done—it’s until a timer goes off. These kids will sometimes squeeze off a little BM and think they’re done long before they’ve emptied, so you need to reinforce a new habit of relaxing and taking one’s time. I encourage bringing a GameBoy or iPhone or book or something for distraction. Maybe a Wall Street Journal, if your child is into investment banking. Whatever it takes.

From a diet point of view, you ought to encourage more water, more fruits and vegetables, more whole grains, and less dairy. Having said that, it’s very difficult to get children to make big changes in dietary habits, and rarely do diet changes alone fix significant constipation in kids.

Almost all families struggling with constipation will need to use a stool softener of some kind. Natural ones include fruits and fruit juices rich in sorbitol, like prunes, mango, or pears. Apple juice is popular, but isn’t a very effective stool softener. Ground flaxseeds or other sources of bran or insoluble fiber can help soften stools only if the child also drinks extra water. Without extra water, bran products themselves are constipating.

The most popular medical treatment for constipation is PEG 3350, often marketed as “Miralax” or a generic equivalent. This is a white powder mixed in a drink. Once the crystals dissolve, Miralax is flavorless. It helps constipation by drawing more water into the stool. Miralax is FDA-approved only for the short-term treatment of constipation, but it’s routinely used as a long-term maintenance drug safely. Other medicines used to treat constipation include Lactulose, Senokot, and Dulcolax. If you need to use medications, you ought to get more-specific instructions from your child’s pediatrician, who can also screen for rare-but-important medical causes of constipation that might be present.

Constipation isn’t fun, and it can cause significant problems including discomfort, embarrassment, and urinary problems. Unfortunately, some kids learn early on that pooping hurts, and those kids often continue to have issues with stool holding for years. If your child is constipated, please fix it, and keep it fixed. Talk with your pediatrician for more-specific advice, and don’t give up or stop treating it until it’s fixed for good.

Short questions on cramps, SIDS, lumps, spatulas, and suckers

The Pediatric Insider

© 2010 Roy Benaroch, MD

A quick-fire post! Time to clear out the inbox…

Michelle: “Is it possible for girls to have cramps before (about a year or so) they start their period?”

I don’t think that’s likely, at least not that far beforehand. Constipation, stress, poor diet (too much processed food, not enough fresh fruits/vegs/water), not enough exercise, and lactose intolerance would be far more likely.

L asked: “Why do some children develop knots in the leg after immunization injections?”

They’re called “sterile abscesses”, which isn’t a great name—they’re not really abscesses at all. The knots are caused by a local inflammatory reaction, and they’re more likely to occur if the needle was too short or if the child jerked away. The knots don’t really mean anything, and don’t interfere with the way the vaccine works. Expect them to gradually go away in a few months.

Sheri: “My 6 1/2 month old recently started sleeping on his stomach. I put him down on his back half swaddled with his arms out for every sleep. He cries, moves around and eventually rolls over on his stomach for the rest of the night. I know this increases his risk of SIDS but I can’t stop him from rolling over. Can I stop worrying?”

Yes. Stop worrying. The “back to sleep” campaign, which has reduced SIDS by about 50%, encourages parents to put babies on their backs to sleep—but never included any instructions to keep babies on their backs. Once your child can roll to him stomach, leave him there. You don’t have to stand aside his crib all night with a spatula, flipping him back over.

Melissa: “Hi- I was wondering what your opinion was on all of the antibacterial products that are available now and so widely used.”

No good studies have been able to confirm that antibacterial-coated products have been able to reduce infections. I doubt they could have any net effect on the germs that children are exposed to, with the single exception of alcohol-based hand sanitizers. Those have been shown to reduce infections among health care works and in day cares. You want to avoid infections? Try:

• Good handwashing
• Frequent use of alcohol-based hand sanitizers
• Vaccines against preventable illnesses like influenza
• Keeping your children away from sick children
• A good night’s sleep

Antibacterial surfaces, special vitamin supplements (including those “developed by a teacher” or sold by olympians), herbs, wands, sprays, magic air ionizers, and plenty of other gizmos and elixirs are big money-makers for some, and big money-wasters for others. Don’t be a sucker.

That belly ache isn’t all in your head

The Pediatric Insider

© 2010 Roy Benaroch, MD

About 25% of children experience frequent belly aches, and abdominal pain is a very frequent cause of pediatrician visits and school absences. The majority of kids with belly aches don’t have any serious underlying disease, which might lead some parents and doctors to say “It’s all in their heads.” A recent study contradicts that opinion, and  reveals some new insights into the cause of belly aches in children.

First, some terminology. Traditionally, we’ve divided abdominal pain into two categories: “organic” and “functional.” Organic means that some organ is involved or broken—there’s something abnormal you can see on a biopsy or blood test. “Functional” pain is an awkward term, but it means that the pain is arising not from tissue damage or pathology, but from the functioning of the gut. We can’t find anything objectively wrong, but there is still pain. Functional abdominal pain is more specifically often diagnosed as “Irritable Bowel Syndrome” (IBS). The older term Chronic Recurrent Abdominal Pain is discouraged, because of its unfortunate acronym.

So what is Irritable Bowel Syndrome, if it isn’t a disease that you can see or prove with a microscope? We know it runs in families, and that the pain can be intensified by emotional stress. Psychotherapy or treatment for depression can help the pain, at least sometimes, as can regular exercise and stress-reduction strategies. Diet can certainly make IBS worse, especially a diet with lots of refined sugars and weird processed chemicals. All of this has been known for years. What’s new is an emerging understanding of what makes kids (or adults) with IBS different from other people.

A study published in the January, 2010 issue of The Journal of Pediatrics looked at a potential new test that could be used to diagnose IBS. (Skip the rest of this paragraph if you’re extra-squeamish, but you’ll be missing the cool part). The authors determined the “Rectal Sensory Threshold for Pain” in kids with abdominal pain caused by IBS versus children with abdominal pain caused by organic diseases. To do this, a balloon was inserted into the rectum, and inflated until the child reported pain. What they found was that most of the children with IBS experienced pain at much lower pressures than children with organic disease. The authors suggest that this method could be used as a diagnostic tool.

The study shows us something more important about children with IBS: they have an increased sensation of pain to stimuli that doesn’t cause pain in other children. Both groups of kids had the same amount of distension from the balloon—not enough to cause any harm—but the children with IBS found that procedure painful. The biopsies and tests are normal because there isn’t any actual tissue damage, yet the pain sensitivity these kids experience is very real and testable. Irritable Bowel Syndrome is a disease of increased sensitivity to pain, when bubbles of air or stool masses or other feelings that most of us do not find uncomfortable cause pain. The pain itself is real, and isn’t “all in their heads”.

If your child is experiencing frequent abdominal pains, go see your pediatrician. There are other potential causes that need to be explored—lactose intolerance and constipation are both common. Usually, a careful history and physical is all that’s needed to confirm a diagnosis, though sometimes some blood or stool tests are needed. If your child does have Irritable Bowel Syndrome, it’s good to know that it’s not serious, and that some simple lifestyle and dietary modifications can help. More severe cases can be referred to a pediatric gastroenterologist for further evaluation and treatment. And the balloons are optional.

When is a belly ache “real”?

Holly asked: “My almost-3-year-old twins have recently started telling me on occasion that their tummy hurts. It almost seems like it’s a catch-all phrase for any malaise, but I also think that they have figured out that a statement like that brings on immediate attention. So far, in every instance, either food or a distraction has resolved the issue, but I did wonder if there’s way to recognize when the complaint should be taken seriously – absent the obvious symptoms like fever.”

I love this question. It speaks to something I consider my main goal as a doctor: teaching parents to become self-reliant, and teaching them how to teach their own children to become self-reliant. It’s a circle-of-life thing, without the smarmy Elton John soundtrack, sort of a recursive zen way of looking at what I consider the point of my life as a parent and a pediatrician. Teach parents how to deal with belly aches in a way that helps their own children deal with their own belly aches, that’s been a good day.

I wrote a chapter, called “Communication Remedies,” about this in Solving Health and Behavioral Problems from Birth through Preschool. It’s sort of a whole philosophy of parenting, plus a practical guide to dealing with things like common headaches and belly aches. Here’s an excerpt:

Any body complaint can be caused by social stresses or psychology. Think especially about this sort of problem when a preschooler complains about any of the following symptoms:

• Belly ache
• Dizziness
• Headache
• Tiredness
• Sleep problems

I’ll go more into the various causes of these problems in other chapters, but it is important to not always assume any of these has a “medical” cause. More frequently, there are both biologic and psychological issues at work, and to help a child feel well parents should be prepared to look for the stresses that are contributing to the symptoms.

A good scheme for listening and responding to a child’s complaints follows these steps:

1. Listen right away. Don’t force a child to get your attention with more dramatic or painful symptoms. When a child complains of a headache, it’s best to quickly listen.

2. Listen with attention. Show with body language that you are listening and interested.

3. Try an “explore question”. Often, a quick “How was school today?” type of question will get you to the root of the problem. If you don’t ask, they won’t tell.

4. Encourage the child to discuss the symptoms. Ask a few brief clarifying questions to allow the child to discuss the pain for a few moments. This allows the child to talk with your attention, which is therapeutic. This step should not last longer than 30 seconds or so. Use open-ended questions like:

• Tell me about the pain.
• Where does it hurt?
• What does it feel like?
• Why do you think it hurts?
• What could I do to help it feel better?

Avoid yes/no or leading questions:

• Does it hurt right here?
• Does your throat hurt too?

5. Touch the child. Touch is powerful and important. Try a kiss in the middle of the forehead for a child’s headache. You’ll be amazed how well it works.

6. Attack the problem. You need a firm, confident plan. It may include medicine (for example, a safe antacid for belly pain, or acetaminophen for a headache), comfort measures (hugging a heating pad), or resting in a certain way (“Lie here on your side for five minutes.”) The plan should always include specific steps and be time-limited.

7. Confirm the child is better. Use a statement, not a question. Say “I am glad you’re starting to feel better.” This is a special phrase: it does not imply that the pain is all gone, it is reassuring, and it helps children feel better by making their parents happy. It’s magic.

8. End the encounter. Gently change the subject and encourage your child to play, with a specific suggestion.

• Good: “I’m glad you’re starting to feel better. Go play with your sister.”
• Better: “I’m glad you’re starting to feel better. Go play dress up with your sister.”
• Best: “I’m glad you’re starting to feel better. Let me help you get your cowboy vest on to play dress up with your sister.”

I’m sometimes asked, “What if it is really serious?” Families will not miss a serious illness by first following the scheme above. If the problem is something to worry about, children will show you with their behavior that they’re truly ill. If after a few days symptoms persist in an otherwise well appearing child, consider a trip to the doctor.

Reassuring factors: (these are clues that pain is not caused by a serious medical problem):

• Pain in a vague location, or pain right in the belly button.
• Symptoms that are difficult to describe or talk about.
• Symptoms that only occur on school days, or are especially bothersome the few days after a school vacation.

Concerning factors: (clues that should raise your concern)

• Associated symptoms like fever, vomiting, diarrhea, or weight loss.
• Symptoms that wake a child from sleep.

Many symptoms have no definite medical cause, but are still stressful and upsetting to children. Watch how children act to help determine if immediate medical concern is justified, and listen to what they say to find ways to help alleviate the symptoms.