Kids: Mommy, My Tummy Hurts

Oct 16, 2012

Ten to 15 percent of school-aged children will seek medical care for recurrent abdominal pain. But parents need not panic. Stomach aches in kids are not only common, they are typically not serious. Many of them are caused by food issues, such as lactose intolerance, or stress, especially at the start of the school year. In Tuesday's Health and Science section, pediatrician Howard J. Bennett offers his insights on stomach aches in kids -- when to worry, when not to worry and tips for preventing them.

On Tuesday, Oct. 16th at Noon EDT, Bennett answered your questions about why so many kids belly ache about belly aches and what parents can do about it.

Hi Everyone,

I'm happy to have an opportunity to answer your questions about the article I published in today's Health and Science section. Howard Bennett

Hi My son, who is eight, has suffered from abdominal pain off and on for the past several years. He had reflux as an infant and experienced no further symptoms until he was about five. When he was six, he started taking Prilosec, which seemed to help, although it appeared to cause terrible headaches. He came off of that after 12 months, no further atomach pain or headaches. At the start of the school year, just like you mention in your intro, the pain was back with a vengeance. It wasn't reflux, because the mylanta had no effect. It seems much better now, but I am concerned that I might be missing something. What symptoms should not be ignored and is it normal to have recurring abdominal pain with no identifiable cause? His pediatrician doesn't seem too concerned, but of course, I am.

Thanks for writing. The most important thing parents and doctors can do in this situation is to get a good history of the problem. When does the pain occur? How long does it last? Is is associated with anything? Etc. As I said in the article, pain that occurs during school but not on weekends or vacations usually has a stress component. Pain that occurs after meals or before defecating often relates to lactose intolerance or constipation. Remember, that constipation is not always obvious and parents have to check what's going on (or more specifically, what's coming out!) to know if their child has a problem in this area.

 

In terms of "missing something," there are  symptoms that suggest a more serious problem might be going on. The most concerning symptoms are recurrent vomiting or diarrhea, weight loss or failure to gain weight, waking up from sleep with stomachahces, being fatigued, and not looking well.

 

Having said this, celiac disease affects about one in 130 people in the United States and this discorder can have very subtle findings. If a child has recurrent pain that is not obviously due to the "big three" I mentioned in the article, checking for celiac disease is appropriate.

 

If your pediatrician hasn't reassured you that nothing is wrong, I would let him or her know that you still have reservations about what might be causing your child's symptoms. If this still leaves you unsure, I would suggest getting a second opinion from a pediatric gastroenterologist.

We ignored our child's belly aches for too many years. Later we found out she was bullied and picked on her early school years.

I'm glad you finally figured out the cause of your child's distress. There is an epidemic of bullying in our schools and it is often subtle. Bullies don't always hit or steal someone's lunch money. Sometimes they threaten in other ways.

Whenever a child is acting odd, parents should consider the possibility that he is being bullied. Before kids open up, it helps to tell them that bullies often threaten to hurt someone if the child tells the truth about what's been happening, but bullies almost never carry out that threat. Kids NEED to tell a grownup if they are being bullied.

As a child ( I am now 60), I had stomach aches before school, especially when there were tests, etc. When working as a teen as a hostess in a busy restaurant, I often got a headache just before the lunch rush; once I realized what was happening, I managed to settle myself down - got through the headaches, and they stopped. I didn't understand the psychology of course, but figured it out. Kids can also be taught to understand what's happening and overcome it.

You are so right. One way to communicate this to our children is to be forthright about things that happened to us as kids. It's easier for a child to tell his mom and dad something that's bothering him if he knows his parents struggled with a similar problem growing up.

My now 13 year old daughter had recurrent stomach aches. Several months ago her pediatrician told me to get Zantac or Prilosec. The stomach aches stopped for about two months while she was on Zantac, but then returned. She went to a pediatric GI specialist who eventually diagnosed a hiatal hernia through an endoscopy, however, the hernia did not show up on a subsequent barium swallow. (As a side note, she developed eosinophilia from the Zantac, so he put her on prescription Prilosec). She's had no problems since taking the Prilosec for two months, but is still on a restricted diet (which she hates) for GERD. Is it possible for the hernia to go away, can she safely take Prilosec long term? She wants to eat all of her favorite foods, but I am afraid of the stomach aches returning if she goes off Prilosec. Isn't there a risk to keeping the stomach from producing some acids? Thanks.

Although I have an interest in gastrointestinal problems, I am not a pediatric gastroenterologist, so it's a good idea to review these questions and my answers with your child's doctor. That being said, I have GERD myself so I have dealt with it as a patient as well as a doctor.

 

The first thing I'd say is that it is very important that your daughter takes her Prilosec correctly. This type of medication, which is called a PPI, should be taken 30 to 60 minutes before eating to work properly. Over the years, I have found that for me, taking it 30 minutes before eating is better than 60.

 

I developed a hiatal hernia and GERD as an adult. For me, I know the hernia will always be present. I have been told by my GI doc that the two together make reflux worse. I sometimes take Zantac at night, but usually 40mg of Prilosec in the morning is enough. The other thing I found is that I am very sensitive to changes in generic drugs. The generic for Prilosec is called omeprazole. I used to get my medication at CVS and they changed generic brands frequently. This caused trouble with my reflux symptoms. I now go to an independent pharmacy, which allows me to get the same generic (the Watson brand) every month.

 

There are specific foods that GERD patients are told to avoid. The most common include caffeine, alcohol, peppermint, citrus, garlic, onions, high-fat foods and, of course, overeating. I have experimented with this and find that caffeinated sodas don't aggravate my reflux, but citrus-based products like orange juice and Italian food are awful. If your daughter is reasonable about this, she can experiment with her dieat as well.

 

It helps reduce reflux symptoms if you sleep on your left side. I also sleep with the head of my bed elevated six inches, but that's a lot for a teenager to do. It also helps to chew sugarless gum if your reflux is acting up. This works because saliva is "basic", i.e., it neutralizes stomach acid. It also helps "push" things back into the stomach.

 

Stomach acid is one of the body's lines of defense against bacteria and viruses. There is research to show that patients who take PPIs (like Prilosec) are at increased risk for pneumonia and gastrointestinal viruses. The risk is small, however. I have been on PPIs for 20 years and have never had pneumonia. I have had two intestinal illness from food, however, that my kids and wife handled better than I did.

 

My last comment has to do with your daughter's abdominal pain. GERD can cause nausea and mild upper abdominal discomfort, but it is more likely to cause heartburn or chest pain than the typical type of "stomachaches" I see all the time. If your daughter's abdominal pain recurs and is around her belly button or below, I'm not sure it's due to her reflux, and you might want to explore this with her GI doctor. It might still have a stress or constipation component.

 

I hope these comments help.

Are stomach aches different for kids and adults? It seemed like I lost my lunch more often as a kid than I do as an adult. I don't know if that is just a sign that I know better - what foods to avoid or have stronger control to keep things from coming back up.

In general, children are more prone to stomachaches than adults. In most cases, this is because they get more viral infections that are associated with intestinal symptoms and because their diets are less balanced. In your case, it's possible you had some food allergies that resolved as you got older or (as you said), you learned which foods bothered you and avoided them.

Could you please address the growing prevalence of celiac disease? This can be another source of "tummy ache." It took ages to get a diagnosis for my daughter. Also I have two other kids who did not test positive for gluten antibodies, but have herpetiform dermatitis and are restricting gluten consumption.

I don't know if the prevalence of celiac disease is growing, but it is being diagnosed more because doctors and the public are increasingly aware of the variety of ways it shows up. In the past, pediatricians were taught to expect celiac disease to present in young children with abdominal pain, distended (swollen) abdomens and poor appetite. Now we know that children can have subtle abdominal pain, diarrhea, constipation, nausea, poor growth, unexplained anemia and fatigue. Adults can show all of these symptoms plus infertility, osteoporosis and ones I'm probably not aware of.

 

I think celiac disease should be considered in any child whose symptoms do not fall into the "big three" I discussed in the article. Occasionally, doctors and parents have to think outside the box. One of my teen patients has lactose intolerance and anxiety, but his intestinal complaints continued after each of these issues was addressed. I sent him to a pediatric gastroenterologist for an upper endoscopy, and he was diagnosed with celiac disease.

I've been hearing about probiotics for everything from stomach aches to anxiety. Would love your thoughts on whether and when they are indicated, and if so, what kinds do you advise? There are so many different varieties available.

From my perspective as a primary care doctor, probiotics are still "new." By that I mean reseach has been published in our pediatric journals for the past five to ten years. As a result, all of the studies a doctor would like to rely on haven't been published. 

 

I use probiotics mostly to prevent or treat the diarrhea that's associated with antibiotics. There is also some evidence that it might help toddlers with eczema.

 

In terms of abdominal pain, research has shown that probiotics help some adults with irritable bowel syndrome. Consequently, I recommend them to my patients with those types of symptoms. The drug that my GI colleagues have tended to recommend in this instance is called Align, but that does not mean that other probiotics would work as well. You should not take any medication, including non-prescription ones without discussing it first with your doctor.

 

 

Hello, My 2nd grader often tells me that his tummy hurts after he eats dinner and that he wants to go lie down. It's hard to tell if it really hurts, or it is because he is full, doesn't want to finish his food, or wants to do something else. We think he's lactose intolerant because we noticed he's gassy after drinking milk or eating ice cream, and his father is lactose intolerant. We give him Lactaid milk and I think the gassiness has improved (but he drinks regular milk at school because he doesn't want to be different). I still give him cheese and yogurt. He has a regular bowel movement everyday and is rarely constipated or has diarrhea. I'm not sure about the cause(s): food, anxiety or something else. I don't know if I should try elimination of dairy or gluten, or if he will 'grow out' of this. Could he still have some food intolerance if he has regular and normal elimination? Thanks for any guidance.

In the article, I mentioned that lactose intolerance is not an all or nothing phenomenon. A person may be able to handle a lactose-containing food/drink for a few days during the first part of the week, but have trouble later. The easiest way for you to deal with this would be to use lactose-free milk at home and have your child take the Lactaid (or generic) medication with milk or milk products at school or any other time of the day. If this is not practical, there is a non-prescription medication called Digestive Advantage for lactose intolerance that is taken once a day (every day!) and gets around the need to take pills at school.

 

Have abdominal pain after eating is very common with constipation. Some kids have two firm stools per week and have no symptoms. Other kids have one formed stool per day and do have symptoms. I would suggest looking at all of your child's stools for a week (I know it's gross!) to be sure you know exactly what's being produced. I would then consider adding foods to the diet that foster softer stools (prunes, pears, etc.) or give him a non-prescription medication like Miralax. The goal would be to have your child produce two soft, easy-to-pass stools per day. If you accomplish this task and the pain continues, it's probably not due to constipation. As I said earlier, it's a good idea to discuss these options with your doctor before moving forward.

Hate to be blunt, but unless my kids (now teens) were throwing up, had nasty diarrhea, a fever or a rash with fever, they were expected to get up and at it. If you let a little stomach ache or sniffles knock you out for the day, well, good luck to you in life! I see too many parents letting their kids stay home for the weakest of excuses, including stomach aches. I think this coddling leads to problems later when kids aren't able to "push through" on other things - I have seen it among my kids' teenage friends.

There are clearly times when people need to "work through" their pain/discomfort/anxiety, etc. But it's also important to make sure someone doesn't have a treatable cause for his or her symptoms. In my opinion, recurrent abdominal pain fits into this category.

For the past month my 8-year old son has been reluctant to go to school (3rd grade), complaining of a stomach ache. We are relatively certain it is not physical, but more of an emotional issue. Some days he goes to the nurse's office three times, other days he's been late getting to school. It seems to come and go...but often prevents him from getting to school on time. It is hard to pinpoint what exactly is bothering him, but we're pretty sure it's "nerves." He does say that other kids in his class can be disruptive, and that he finds the cafeteria loud. We have talked to the counselor at school. They've observed him in class and recess and say he appears to be fine, interacting with other kids, etc. He does tend to keep his emotions to himself, as it is difficult for him to express what he is feeling. The question...do we wait for this to pass? Is there anything else we can do besides being understanding, listening to him, etc?

It sounds like you're on the right track. Some children are less communicative than others with this sort of thing. Your son is THE person I wrote my book for. It addresses stress-induced abdominal pain in a way that makes sense and allows the child to deal with his problem. So if you don't mind me plugging my book, I'd suggest you pick up a copy of Max Archer and the Case of the Recurring Stomachaches.

Research is showing a correlation between high folic acid and new onset irritable bowel problems in children. Are you aware of the research and do you ever check UMFA - Unmetabolized Folic Acid? Or check Vitamin B12 levels in your patients with IB? Folate and Vitamin B12 work together for proper cell production in the digestive tract. It appears that synthetic folic acid (unlike natural folate) can build up in children if they don't have enough B12, or if they have common variations in the MTHFR gene for folate metabolism. And because folic acid in the food supply corrects the anemia once seen in B12 deficiency, it seems that not all physicians know you need to test for B12 deficiency directly, not rely on a CBC.

I have not heard about this association, but appreciate your bringing it to my attention. I have copied your comment and will review it with my pediatric GI colleagues at Children's National Medical Center. They are great resources for primary care doctors like myself. 

Long term use of a Proton Pump Inhibitor will cause B12 deficiency, which in turn will impair healthy cell production in the digestive tract. Why aren't physicians warning patients about this, and keeping an eye out for the multi-system and polyglandular problems that will develop?

I can only speak for myself on this front, but the treatment of GERD was not the focus of my article. I have GERD and have been taking B12 for years. My internist told me to take it because B12 absorption decreases with age and in a stomach that is less acidic, i.e., someone taking PPIs like Prilosec. The majority of my patients with reflux take H2 blockers like Zantac. The ones that do take PPIs don't take them for long periods of time.

Last winter my now 2.5-year-old often vomited when she was suffering from a bad cold. She'd eat fine, then start coughing (not choking), then projectile vomit everything in her stomach. No fever or other signs of flu and she had a healthy appetite. The pediatrician told us it had to do with her swallowing snot (ugh). Are there ways to avoid facing this again this cold season? Foods to avoid?

Aren't kids great! One of the first things we learn to deal with as parents are the various bodily products that shoot or drip out of our children's bodies. This was an easy step for me because my patients had been doing the same thing to me for years.

 

I agree with your pediatrician. Children swallow lots of mucus when they have a cold or the flu and this mucus appears to "annoy" the stomach. When you add the fact that children vomit more easily than adults, you have the situation you described above.

 

In terms of treatment, some parents find that giving their kids milk with colds often makes them vomit more. I have never seen any research to this effect, but you can give it a try. It is important to keep your child hydrated when he's sick, and for most kids, drinking milk is better than not drinking anything at all.

 

You will undoubtedly run into advertising that suggests you give your child "mucus-thinning" agents to loosen their mucus. Unfortunately, this stuff doesn't work in children.

 

Finally, at some point your child will learn how to blow his nose. You might speed up this process by teaching him to blow into a tissue that you suspend from one finger to get it to move. First, he can blow with his mouth, then with his nose. Make a game of it and practice the technique before he is sick. That way, there's a better chance he'll be able to do it with his next cold.

Here is the research showing high folate levels in children with bowel problems. Controls (without bowel problems) had higher natural folate in their diets, but not in excess in their bloodwork. Children with bowel problems had high folate from folic acid fortification of foods and vitamins. For this reason, doesn't it seem wise to check these levels? Unmetabolised Folic Acid, Vitamin B12, Homocysteine (toxic metabolite that will build up) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2647761/

Thanks. I will check it later today.

There is a high correlation between elevated homocysteine (an indicator of impaired B vitamin status) and Celiac. It may be that having an opposite extreme of vitamin status (high folic acid in the presence of low B12) has become much more common in the age of mandatory folic acid fortification of all flour products. This may be the important epidemiological thing to look at -- as these digestive disorders appear to be on the rise. (Treating B12 deficiency with folic acid increases all sorts of disease risks.)

This is very interesting. I will check this out to investigate its impact in the pediatric population.

My 12-month old son is breastfed and receives solids 2-3 times a day. Since about month three, I have been dairy free and have also been gluten, egg, and soy free the past 2.5 months because he has difficulty sleeping due to an upset stomach. My question is: where do I go from here? I feel as though I have exhausted all of my options in terms of treating him naturally and eliminating a great deal from my diet. The next step I am considering taking is the GAPS diet for either him (if he's weaned) or the two of us. Do you have any advice to offer? Thanks!

This is a tough one because you've had a problem that's been going on for a long time. Babies wake up at night for lots of reasons. Parents often assume it's due to an upset stomach because a baby cries, tenses his tummy or passes gas. While it's true that intestinal problems can cause these symptoms, babies can exhibit the same symptoms with teething, a viral illness or just because they aren't "good" sleepers. Also, whilc it may seem like it had an effect, making changes in your diet may or may not have been the thing that made a change in your child's sleep.

 

I am assuming you discussed these concerns with your doctor because a detailed history about the baby's sleep patterns, growth and medical information is essential to know what you should do next. If you haven't talked to your doctor about this, you should. If you have talked to your doctor and didn't get the information you need, I'd suggest seeing a pediatric gastrointestinal specialist.

My 5-year-old also complains about stomachaches after eating dinner sometimes. His stools are typically loose, though not to the point of diarrhea. His diet consists mostly of meat, veggies, fruits and yogurt (he's not a fan of most grain-based things or other dairy products). I suspect a little more fiber would do him some good, but aside from high-fiber veggies, is there anything he can eat to boost his intake without a supplement like metamucil?

Before I respond to the grain question, you might want to consider whether you child is mildly lactose-intolerant because that's a common cause of "loose" stools. It can also happen if the child eats lots of fruit. You can test for this easily by trying lactose-free milk for a week or so.

 

As far as grains go, here are some items to consider (in case you havenb't already): hot or cold cereal, whole grain rice or pasta, French toast made with whole grain bread, toast cut up into cool-looking designs with peanut butter and jelly, frozen waffles or pancakes made from whole grains, smoothies with some added fiber like a small amount of oatmeal. 

 

There are probably some websites or books you could check that have child-friendly, high-fiber recipes for children.

There are about 30 seconds left to go in my online chat. I'd like to thank everyone who wrote in with a question. I hope I answered them to your satisfaction. If anyone has a followup question, you can send it to my website: www.howardjbennett.com. HB

In This Chat
Howard J. Bennett
Howard J. Bennett is a board-certified pediatrician with thirty years of clinical experience and author of several books including, "Waking Up Dry: A Guide to Help Children Overcome Bedwetting." He was appointed director of pediatric education and won the first Outstanding Teacher Award given in his department. Bennett has had a private practice in the District since 1991. But continues academic affiliation as a clinical professor of pediatrics at The George Washington University School of Medicine.

Regularly listed as a "Top Doctor" in Washingtonian magazine, Bennett has appeared on a handful of national television shows, including NBC Nightly News, World News Tonight, and CNN. He also contributes to GreadDad.com and Jack and Jill magazine, and writes the Ever Wondered column published in the Washington Post. The column appears in KidsPost, which is published in the paper's Style Section.
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