The Australian Kids' Health Book: The Essential A-Z Guide to Emergencies , Baby Care and Common Childhood Illnesses

ABDOMINAL PAIN AND VOMITING

Abdominal pain in children is very common and the list of causes is huge, varying from trivial to life-threatening.

Here are descriptions of some common causes of discomfort as well as warning signs that may indicate something serious is going on.

The first question is whether a child with severe abdominal pain requires urgent surgery. The age of the child makes a big difference to the level of concern. In younger children, the signs are often subtle and this can add to the difficulty in making a diagnosis.

Vomiting is a sign that accompanies many illnesses and has to be taken in context. In a child who also has diarrhoea, the answer may be as simple as viral gastroenteritis. However, there are some types of vomiting that should be taken more seriously.

Green vomit (bile-stained)

Unpleasant as it is, most people know what normal stomach-contents vomit looks like. However, if the vomit is green, this is a warning sign of potentially serious illness. Green vomit contains bile, which is produced and squirted into the bowel by the gall bladder some distance after the stomach finishes. A vomit with bile in it suggests there is an obstruction some distance past the stomach. Urgent investigation is required.

Blood in vomit

Blood in the vomit is not unusual, especially if there has been forceful vomiting as this can cause a small tear in the lining of the stomach and oesophagus (food pipe) and a small bleed. In these cases, the vomit is streaked with blood; on the other hand, a large amount of blood in the vomit needs urgent investigation to rule out serious causes.

Babies under six months

In young babies (under six months of age) with abdominal pain and vomiting, the following conditions need to be excluded.

Hernias

Hernias in young babies are very different to adult hernias. Hernias are a bulge of gut forcing its way through a weakness in the abdominal wall. The big risk is that the gut will come through the weak spot and then swell and be unable to be put back into the abdomen. This will produce serious and life-threatening obstruction. In infants, hernias in the groin can get stuck much more easily than in adults and need urgent management. In short, any baby with an unexplained lump in the groin needs assessment by a surgeon if they are well and urgent assessment in the emergency department if the groin lump begins to swell and the baby appears unwell with vomiting.

One type of hernia that does not cause problems is an umbilical (belly button) hernia. This is a hernia lump that pops out at the umbilicus. This type of hernia almost never gets stuck and does not need treatment. The vast majority go away by themselves but it can take as long as two to four years. Traditionally, parents used to tape a coin over the lump, but this has no effect. If the lump is still present at four years, a small cosmetic operation can be carried out to repair it. Most surgeons would not recommend operating before then.

Projectile vomiting and pyloric stenosis

There is a condition in babies called pyloric stenosis which can produce projectile vomiting. This is more common in boys and is caused by the muscle surrounding the end of the stomach becoming thicker over the first few weeks after birth and blocking the stomach from emptying. It also goes under the scary name of a pyloric tumour, however it is not a growth but simply a thickening in the muscle. The usual story is of a baby who has been doing well for the first three to four weeks of life who then develops progressively more vomiting at around four to six weeks of age. In pyloric stenosis, the vomiting is always food-coloured and not green-stained. This information is very helpful to doctors when making the diagnosis. The baby becomes increasingly hungry because everything that goes into the stomach is vomited out in a spectacular fashion—projectile vomiting. My son developed this condition at six weeks, and when we arrived in the emergency department he did the most spectacular projectile vomit across the whole department. After this, no one was in any doubt about the diagnosis.

The condition is usually diagnosed by ultrasound and a small operation is performed to cut along the thickened muscle and open it up. Generally, babies start feeding within hours of the operation—then carry on making up for lost time. This is not a condition that recurs.

Older children

Appendicitis

Many parents of children with abdominal pain are concerned about the possibility of appendicitis. The appendix is a small, blind-ended tube of gut that is attached to the large intestine in the right lower section of the abdomen. It does not serve any useful purpose but can get inflamed, infected and, in severe cases, burst. Typically, the pain of appendicitis starts in the centre of the tummy and then moves to the right lower area. There is usually a temperature, vomiting, loss of appetite and a generally unwell-looking child. Unfortunately, the typical picture may not occur in children and the diagnosis can be tricky. Consequently, abdominal pain with the features in the list on page 6 should be assessed by a doctor. Sometimes, if the diagnosis is not certain, it can be safe to watch and wait. The condition may turn out to be mesenteric adenitis, which is not problematic: just as lymph nodes in the neck can swell with infections, lymph nodes in the abdomen can swell with infections. This causes pressure on the gut wall which gives a pain similar to that of appendicitis. However, it is not serious.

Because the diagnosis can be difficult to make, ultrasound and, in rare instances, CT scan may be used to look at the appendix. Even with this help diagnosis may still be unclear and surgeons may, after discussion with the parents, elect to remove the appendix in case it is inflamed. Remember that children with abdominal pain that includes features in the list on page 6 should be assessed by a doctor within four hours if possible.

The appendix is on the right side of the abdomen. Appendicitis pain often starts near the belly button and then moves to the lower side of the right abdomen.

Testicular pain

The testicles dangle in the scrotum and each is held by a long cord that contains, among other things, its blood supply. Occasionally, the testicle can become twisted and then the blood supply can be cut off. This is known as testicular torsion and it causes severe pain in the testicle. The testicle may die from lack of blood. The peak age for this to occur is 12 to 18 years, although it can occur at any age.

Sometimes there is a story of trauma to the testicle beforehand but often there is no obvious cause. The critical aspect is that there is only a limited time to achieve a repair before the testicle dies. An operation is required to turn the testicle and fix it in position. If repairs are done within six hours of the pain starting, almost all testicles can be saved. After 12 hours, this drops to only 20%. Consequently, all testicular pain must be evaluated as soon as possible in the emergency department: a successful surgical outcome depends on early presentation and diagnosis. Although there are other causes for testicular pain, such as infection and inflammation, testicular torsion needs to be excluded before an alternative diagnosis is made.

Note that testicular pain can sometimes cause pain in the middle of the tummy, so it is important to make sure that pain in the tummy is not coming from the testicle. If in any doubt, seek urgent medical help from your GP or closest emergency department.

Warning signs of significant abdominal pain

Severe pain—unable to walk or walks bent over

Abdominal pain with temperature >38°C

Green vomiting

Blood in the poo

Pain in the right lower side

Pain in the scrotum or testicle

Pain associated with an injury to the tummy

Recurrent abdominal pain

There are many causes of abdominal pain not mentioned in this chapter and these need to be diagnosed and treated. However, a common situation for parents and doctors is a child who has recurrent episodes of abdominal pain with no obvious medical cause. This can be very frustrating.

Children often have difficulty responding to stress and may develop abdominal pain as a means of expressing their feelings. It is important to recognise and validate this pain for the child. If a thorough assessment reveals no physical cause for the abdominal pain, it is important not to make light of the pain as it is a genuine pain for that child—this is not malingering. Other, non-medical options may be helpful in discovering the true source of the pain and the next step is to explore the stresses and environment around the child. It is very useful for parents to have a good understanding of how the child is coping with school, both in terms of academic work and interactions with the peer group. Sometimes there is an obvious problem, such as bullying, which can be addressed. At other times the stresses are more subtle and take time to surface. Patience and support are required. Beware of over-investigation and unnecessary medication.

The good news is that with understanding and time the vast majority of these problems will get better, much to the relief of everybody. A small percentage take a more prolonged course and need the involvement of psychologists to help the child develop coping mechanisms to deal with the pain.

ALLERGY

Allergic reactions worry every parent because of their unpredictable nature and because they seem so common. It is important to define allergy to help distinguish it from symptoms that are similar.

Allergy happens when the body’s immune system fails to recognise ordinary substances, such as foods or pollens, and reacts by inappropriately activating areas of the body’s defence that are usually designed to help rather than to harm. In some cases, such as anaphylaxis (see the explanation below), the reaction can be so severe that it can be life-threatening.

Types of reaction that can be mistaken for allergies include:

Food poisoning—this can cause diarrhoea or vomiting and is usually caused by bacteria in spoiled or undercooked food.

Drug effects—certain ingredients, such as additives or caffeine, can make your child shaky or restless.

Skin irritation—this can often be caused by acids found in such foods as orange juice or tomato products.

Diarrhoea—this can occur in small children from too much sugar, such as from fruit juices. Antibiotics commonly cause diarrhoea because they upset the normal bacteria in the gut.

Food intolerance—eg inability to digest milk due to lack of the enzyme lactase, which is required for this (lactose malabsorption), or coeliac disease, which is permanent sensitivity to gluten-containing products such as wheat and bread. Managing children with coeliac disease (gluten sensitivity) can be challenging as many food products contain gluten. A dietician can provide helpful advice about which products to avoid.

Anaphylaxis

It is important to be able to recognise anaphylaxis and to know what to do in this situation.

Anaphylaxis is a rapid onset of three or more of the following:

Swelling of the face and lips or tongue

Raised red rash which is usually itchy and can look like severe mosquito bites (hives)

Wheezing or difficulty breathing

Drop in blood pressure causing collapse

Vomiting and diarrhoea

It is important to call an ambulance (see page 56) and tell them you suspect anaphylaxis. If the child is known to be allergic to a substance and has an adrenaline self-injecting pen (EpiPen/EpiPenJr), give this injection as soon as possible. If necessary, start basic life support (see page 25) while waiting for expert help to arrive.

To use an EpiPen, first form a tight grip and remove the cap. Then place the black end against the outer thigh. Push down hard and wait for the click. Remove the EpiPen and dispose of it carefully—ensure you don’t injure yourself with the needle.

Food allergies

Allergic reactions can be triggered by almost any food but there are groups of foods that are much more likely to create problems than others.

Over 90% of food allergies are caused by:

Tree nuts (walnuts, almonds, pecans, pistachios, cashews)

Peanuts (technically, the peanut is considered a ground nut)

Shellfish (prawns, shrimp, lobster)

Eggs

Fish

Cow’s milk

Soy

Wheat

Allergic reactions to these can be restricted to the skin, with the characteristic hives rash, but can also be of the more severe anaphylactic variety. Hives consists of raised red patches of skin that are itchy. They can be localised to one area or spread rapidly across the whole body.

There needs to be an initial introduction to the food to develop the allergy in the first place. Consequently, the first time one of these foods is eaten there is normally no reaction, the second time may cause a mild or severe reaction and any further episodes may be more severe. The allergic reaction may intensify with each further contact. Often the child has been unknowingly exposed to small traces of the food in the past, which is why an apparently first exposure can be severe.

Egg and milk allergies are often ‘outgrown’ by the teenage years but peanut, shellfish and tree nut allergies are much more likely to be lifelong. Unfortunately, of all these, peanut is the one allergy that only 20% of children outgrow as they become teenagers and adults.

Some foods can cause a more delayed type of reaction, occurring over hours and days rather than minutes. The reaction occurs via a different branch of the immune system and consists of symptoms such as vomiting, tummy pain and diarrhoea. As the symptoms are not so closely connected to eating the food, it can be hard to diagnose and may need the