Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Use age, time course and whole-child examination to distinguish self-limiting or functional pain from surgical, inflammatory, urinary, metabolic, gynaecological and safeguarding emergencies while avoiding indiscriminate testing.
Age reshapes probability. Infants may show pallor, drawing legs up, poor feeding or lethargy rather than verbal pain. School-age children can localise and describe migration. Adolescents need confidential urinary, sexual, menstrual, pregnancy and substance history while maintaining safeguarding responsibilities. Ask about previous surgery, IBD, sickle disease, diabetes and family migraine or inflammatory disease.
Use ABCDE before a detailed abdominal examination. Check glucose in an unwell or vomiting child. Inspect breathing because pneumonia can refer pain. Palpate gently from the least tender region, assess percussion and bowel sounds and examine groins. Genital examination is essential when torsion is possible. Rectal or vaginal examinations are rarely first line in children and require a specific indication, consent and experienced practitioner.
Investigations answer a question. Urinalysis supports UTI or stones; pregnancy testing changes imaging and emergency differential; FBC and CRP support but do not rule appendicitis in or out. Ultrasound assesses appendix, intussusception, gallbladder, kidney, pelvis and testes without radiation but is operator dependent and a non-visualised appendix is not a negative diagnosis. Serial examination by the same team can be more informative than one broad scan.
Gastroenteritis, appendicitis, IBD, coeliac disease and pancreatitis produce pain through mucosal or visceral inflammation with disease-specific associated features.
Intussusception, malrotation, adhesions, incarcerated hernia and gonadal torsion cause ischaemic or distension pain and demand rapid anatomical assessment.
UTI, calculi, dysmenorrhoea, ovarian cyst or torsion and pregnancy complications may present primarily as lower abdominal pain.
Functional abdominal pain reflects altered visceral sensitivity, motility and central processing without structural injury, often influenced by stress and sleep.
Stretch or inflammation of hollow organs produces poorly localised midline pain with autonomic nausea and pallor.
Inflammation reaching the peritoneum creates sharp localised pain, guarding and reluctance to move, walk or cough.
Shared spinal segments allow lower-lobe pneumonia, gonadal disease and abdominal organs to generate pain distant from the source.
After infection or during stress, peripheral and central amplification can sustain genuine recurrent pain despite absence of ongoing tissue damage.
A still child with localised tenderness, involuntary guarding and pain on cough or movement has parietal irritation.
Waves of severe pain with pallor, vomiting and symptom-free intervals suggest bowel contraction against obstruction.
Vomiting, dehydration, deep breathing, polyuria and weight loss can indicate diabetic ketoacidosis rather than primary gut disease.
Recurrent pain with normal growth, preserved examination and no nocturnal, bleeding or inflammatory warning can be diagnosed positively.
Testicular or ovarian torsion may be reported as lower abdominal pain, requiring direct age-appropriate examination and imaging decisions.
Progressive central-to-right-lower pain, anorexia, fever and movement tenderness supports appendiceal inflammation, though young children present nonspecifically.
Viral features and diffuse or right-sided pain can mimic appendicitis, which remains a diagnosis requiring adequate exclusion.
Hard infrequent stool, withholding and soiling may cause recurrent pain but does not explain peritonism, bilious vomiting or systemic toxicity.
Lower-lobe pneumonia, pharyngitis, migraine, diabetic ketoacidosis and sickle crisis can produce abdominal pain with clues outside the abdomen.
Recurrent pain with normal growth and examination and no inflammatory or nocturnal red flags supports a positive functional diagnosis after appropriate assessment.
Delayed torsion, obstruction or appendicitis can progress to necrosis, contamination, sepsis and irreversible organ loss permanently.
Vomiting and poor intake cause hypoglycaemia, ketosis, electrolyte disturbance and kidney injury more quickly in young children.
Persistent pain can disrupt school, sleep, activity and family functioning even when structural testing is normal.
Repeated CT, blood sampling and inconsistent explanations increase radiation, anxiety and incidental findings without improving functional care.
Visceral appendiceal pain begins centrally and becomes right sided only when parietal peritoneum is involved.
Failure to see the appendix does not exclude disease when trajectory and secondary signs remain concerning.
Humane pain treatment allows movement and palpation and does not justify delay in surgical review.
A clear mechanism and recovery plan is more useful than saying every test is normal and nothing is wrong.
Forgetting testicular examination in a boy with lower abdominal pain.
Missing pregnancy-related emergencies in an adolescent by avoiding confidential history.
Calling a non-visualised appendix normal.
Using constipation to explain bilious vomiting or peritonism.
Withholding analgesia until a surgeon examines the child.
Repeating tests for functional pain without supporting return to activity.
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A 13-year-old boy presents with sudden lower abdominal pain and vomiting. What examination must be completed immediately even if he does not volunteer scrotal pain?
National guidance is shown before implementation-dependent detail. Apply principles in context and verify current guidance when a decision affects care. Source check completed 27 Aug 2026; clinical approval remains outstanding.
Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes
Treat the cause and physiology. Keep a surgical child nil by mouth, give IV fluids when unable to drink and do not delay analgesia. Early surgical referral is based on trajectory and examination, not on a perfect score. For recurrent functional pain, give a clear positive explanation, maintain school and activity, regular meals and sleep, and address constipation or migraine. Psychological therapy supports coping and function when disability persists; it does not imply invented pain.
Safety-net uncertainty. Specify warning symptoms, who to contact and when reassessment should occur. A child sent home with early diffuse pain needs return for migration, bilious vomiting, fever, persistent focal tenderness, inability to walk, reduced urine or worsening general state. Review growth and new blood, nocturnal or pubertal features in recurrent pain rather than repeating reassurance indefinitely.