Synopsis
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.
- Start with onset, site, migration, character, duration, triggers, movement, stool, urine, vomiting colour, fever, diet, trauma and associated chest, testicular or menstrual features.
- Observe the child before touching: posture, walking, play, pallor, breathing and willingness to hop provide functional information but never replace examination.
- First-line examination includes observations, hydration, chest, abdomen, hernial orifices and genital examination when indicated, with growth and pubertal context.
- Give analgesia early; pain relief does not mask clinically important appendicitis and permits a better examination.
- Select urine, glucose, pregnancy test, FBC, CRP, liver, pancreatic or stool tests from phenotype rather than ordering a universal abdominal panel.
- Ultrasound is preferred initial imaging for many paediatric abdominal, pelvic and testicular questions; MRI may extend assessment while CT is reserved for cases where benefit outweighs radiation.
- Recurrent pain with normal growth and no red flags can be diagnosed positively as functional, with explanation, return to activity and targeted treatment of constipation, migraine or anxiety where present.
- Safety-net all uncertain cases with a defined review interval because early appendicitis and obstruction may evolve after an initially non-specific examination.
Key red flags
Bilious vomiting, distension, guarding, rebound, absent bowel sounds or pain worsened by movement suggests obstruction or peritoneal inflammation.
Sudden testicular or groin pain, a high-riding testis or absent cremasteric reflex requires immediate torsion assessment even when pain is described in the abdomen.
Postmenarchal children need confidential pregnancy assessment where relevant; pain with collapse or bleeding may be ectopic pregnancy or ovarian torsion.
Weight loss, faltering growth, nocturnal diarrhoea, blood in stool, persistent RUQ or RLQ pain, fever or jaundice argues against functional pain.
Polyuria, polydipsia, weight loss, deep breathing or altered consciousness requires immediate glucose and ketone assessment.
Bruising, genital injury, fear, coercion or recurrent unexplained symptoms may indicate safeguarding harm and need sensitive private assessment.
Investigation priorities
Identify evolving localisation, peritonism, hydration and whole-child deterioration over time.
Management branches
Shock, bilious vomiting, peritonism, torsion, severe bleeding or metabolic deterioration is present.
- Use ABCDE, check glucose, provide analgesia and IV access and keep the child nil by mouth.
- Perform focused genital, neurological and abdominal examination without delaying specialist review.
- Obtain urgent paediatric surgical, urological, gynaecological or medical help and targeted imaging.
The child is stable but early surgical disease cannot be confidently excluded.
- Give analgesia and hydration and repeat examination with observation of function.
- Order only phenotype-directed urine, blood and ultrasound tests.
- Admit, arrange rapid review or discharge with explicit time and warning thresholds according to residual risk.