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, 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:
3. 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.
4. 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.
5. 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.
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).
7. 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.