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Abdominal pain accounts for ~ 5% of all presentations to paediatric emergency departments. Surgery is only required in 1-7% of these and there is no specific diagnosis in up to 15%.

This series of posts will look at the best approach to assessing the child with abdo pain, and will cover the common conditions presenting to PED.

When taking the history, be empathic...

Maintain empathy at all times, no matter how tired you are.

Parents are anxious and worried – don’t let this frustrate you!

Use open ended questions to start – let the parents speak, don’t interrupt them early.

Acknowledge that they might be exhausted, especially if they have been transferred from another hospital and have had a long day.

As always, ensure age-appropriate engagement of child.

What are the important specifics to ascertain from the history?

History of pain – if the child is old enough you can ask them directly.

Nature, severity, movement and radiation, worsening and relieving factors, constant vs intermittent etc.

The temporal history is important too.

Ask about associated symptoms – i.e. respiratory symptoms, vomiting, diarrhoea, difficulty passing urine.

Look out for red flags:

  • Bile stained vomiting
  • Flank or back pain
  • Waking at night
  • Not walking

Are there are tips to help work out what's going on?

Ask about journey to hospital – when the car went over bumps.

When asking about nature and severity.

Let the child know that the questions are hard and not to worry too much if they can’t answer.

If the history is long, try to establish if they had any days when they were well.

Ask about stool frequency (beware assuming “constipation”).

Ask about family history of appendicitis.

Time to examine the patient, what should I look out for?

Distraction, be non-threatening, keep parents close.

Positioning – ideally lie them flat but may be better to lie them on parents lap or have parents holding them and examine abdomen from behind – technique will depend on age and level of distress

Observation – RR (measure yourself), work of breathing, movement, level of distress “well v unwell”, sats and heart rate if monitored.

Vital signs – measure HR, RR, BP, temperature

All systems including respiratory and ENT.

Inspection, palpation, percussion, auscultation.

  • Superficial palpation away from site of reported pain – look at their face
  • Deep palpation
  • Liver, spleen, kidneys
  • Masses
  • Percussion

Any tricks of the trade for examining the child with abdo pain?

Don’t stand over child, kneel or sit next to bed.

Keep your arm horizontal, palpate with palm, not the tips of your fingers.  Point of leverage is wrist, not elbow.

Look at their face not your hand when palpating.

Use distraction – ask about age, siblings, school, movies, parents, pets.

If you think the abdomen is distended, then measure it.

Don’t forget hernias, and check the testes.

Mobility, don’t be afraid to try to walk them but don’t push.

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About 

Arjun Rao is a Staff Specialist Paediatrician at Sydney Children’s Hospital.

Author: Arjun Rao

Arjun Rao is a Staff Specialist Paediatrician at Sydney Children’s Hospital.