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These are activities that expand general practice knowledge, skills and attitudes, related to your scope of practice.
These are activities that require reflection on feedback about your work.
These are activities that use your work data to ensure quality results.
Paediatric gastroenterologist and hepatologist Dr Jeremy Rosenbaum, clinical lead of endoscopy services at Melbourne’s Royal Children’s Hospital, affiliate at the Murdoch Children’s Research Institute, senior lecturer at the University of Melbourne, and director of private specialist group Paediatric Gastroenterology Victoria, provides practical tips to help reduce anxiety and over medicalisation, without missing an organic issue.
Children with functional abdominal pain usually report central discomfort around the umbilicus rather than localised pain. Symptoms are often present during the day but rarely wake the child from sleep. Clinical examination is normal, growth is preserved and there is usually no significant gastrointestinal pathology in the family history.
Anxiety, bullying, and family stressors can all contribute to symptoms, Dr Rosenbaum notes.
“Psychosocial drivers of abdominal symptoms are very, very common in kids, especially primary school age kids. And we don’t want to over-medicalise those and get those patients on the merry-go-round of more and more tests.”
Importantly, “functional abdominal pain is a proactive, positive diagnosis,” Dr Rosenbaum says, noting the Rome IV criteria describe over 20 subtypes of functional gastrointestinal disorders—including functional abdominal pain, functional dyspepsia, rumination syndrome and functional constipation.
“And if the patient meets all of those criteria, that’s all that is needed for that diagnosis to be made.”
It’s important to frame a functional diagnosis well, Dr Rosenbaum says.
“Medicalising these types of presentations can lead to patients doctor shopping and things like that. So we want to call out early that it’s probably a functional GI disorder, but we’ll make sure that there’s no red flags before going down that treatment pathway.”
He tells patients that these are disorders of gut-brain interaction, noting many families understand that stress can trigger physical symptoms like palpitations, sweating or headaches.
“It can also cause tummy aches, especially in kids. And disruption of gut function and potentially even disruption of the gut flora can also affect mental health. The relationship between gut and brain runs in both directions.”
“Then we talk about how the gut can be more sensitive in some people, and how the goal is to improve the function of the gut—not necessarily to get the symptoms to zero, but to improve the symptoms so the child can attend school and function as normal.”
It can help to liken the symptoms to a volume control knob, he adds. “And some of our treatment strategies will act to decrease the volume on that knob.”
Psychological support should be considered when appropriate. He recommends gut-focused psychology through professionals like The Gut Centre. If face-to-face care is hard to access, the Nerva app is an evidence-supported tool that delivers online gut-directed hypnotherapy and CBT. School-based counselling may also be beneficial.
Certain features should raise suspicion of organic pathology, including:
“If there are any of those red flags, investigation should be arranged promptly and referral considered.”
Although uncommon, intussusception is a medical emergency that most often occurs in children under age 5. Affected children typically present as significantly unwell; pale, lethargic or floppy with episodes of pain, and sometimes blood in the stool.
Any suspicion of intussusception warrants urgent transfer to hospital, Dr Rosenbaum says. Diagnosis is typically confirmed with ultrasound, and treatment may involve an air enema or surgery.
Initial investigations should be guided by history and examination findings, Dr Rosenbaum says.
Baseline blood tests commonly include:
Stool testing may be helpful in some circumstances, he says.
“Young kids often get giardia and that can be treated with a course of antimicrobials. And faecal calprotectin is more sensitive for bowel inflammation than CRP is in the blood, so it’s very useful to help determine if someone’s luminal symptoms are inflammatory or non-inflammatory.”
There are some caveats, he adds, noting levels are always mildly elevated in infants and toddlers, so testing is not recommended in this age group.
“Other things that can give you a false positive are infections and non-steroidal anti-inflammatories,” he adds.
A normal result makes inflammatory bowel disease (IBD) unlikely, but does not completely exclude Crohn’s disease of the upper gastrointestinal tract or small bowel.
As a practical guide, a result below 50 μg/g makes active IBD highly unlikely; above 200 μg/g warrants specialist referral and likely endoscopy; and 50–200 μg/g represents a grey zone requiring repeat testing in four to six weeks, or specialist input based on the clinical picture.
“If the clinical suspicion remained high, we would probably repeat the calprotectin first but might recommend further investigations.”
Coeliac disease should also be on the diagnostic radar, and it tends to be under-recognised.
It affects approximately 1% of Australian children overall, rising to around 10% in those with type 1 diabetes, Down syndrome, or a first-degree relative with confirmed coeliac disease—so active screening in these groups is important.
If you request coeliac serology on the pathology request, the lab will run the most up-to-date test (which currently includes tissue transglutaminase antibodies and deamidated gliadin antibodies), he says.
For children with a strong family history, HLA-DQ2 and HLA-DQ8 testing may also be useful.
A negative genetic test excludes coeliac disease, while a positive result identifies susceptibility.
“If you’ve got the gene, you may or may not develop coeliac in the future. You need to look at those other tests to determine their risk at the moment. And in the future, if they have symptoms, they should be retested for any signs of possible coeliac, because we don’t know what the trigger is and it can come on at any age.”
Imaging tests should be considered on a case-by-case basis, but they are often unnecessary, Dr Rosenbaum says.
When constipation is suspected, clinical assessment is usually sufficient.
“X-rays are really not recommended for that,” he says, noting they may be appropriate in repeated presentations or telehealth consults.
Similarly, abdominal ultrasound should be reserved for specific circumstances.
“Unless you’ve got a specific question in mind, a general screening ultrasound is not recommended. Sometimes you find unexpected incidentalomas and that can open a whole other can of worms. But if there is focal pain, a family history of the problem, abnormal liver function tests or concern about appendicitis, an ultrasound would be indicated.”
Given the significant radiation exposure, CT scans rarely have a role, Dr Rosenbaum stresses.
“I cannot remember the last time I ordered a CT abdomen for an outpatient. Really, I think it’s a part of a workup for potential surgery only.”
While dietary strategies can be effective, excessive restriction can create nutritional problems and contribute to anxiety around food, Dr Rosenbaum says, noting families have often already tried various approaches.
“So often we need to unpack all of that and consider what we can and can’t reintroduce.”
A low-FODMAP diet may improve symptoms in some children with functional abdominal pain but can lead to low fibre intake.
Dr Rosenbaum therefore recommends a modified paediatric version with support from a dietitian.
There is limited evidence for probiotics in childhood abdominal pain. They are generally safe, and their main drawback is cost. Dr Rosenbaum sometimes recommends them for children who’ve had frequent or prolonged antibiotic courses or those with diarrhoea-predominant irritable bowel syndrome. For families who are keen, he recommends a 4–8-week trial of Lactobacillus rhamnosus GG (available as Culturelle), the strain with the strongest paediatric evidence, continuing only if there is meaningful symptomatic improvement. Alternately, a trial of a broad-spectrum probiotic can sometimes help, but should be discontinued if not.
Children with symptoms suggestive of gastro-oesophageal reflux may benefit from a short trial of proton pump inhibitors, Dr Rosenbaum says.
However, conditions such as eosinophilic oesophagitis, rumination syndrome and hiatus hernia can present similarly, so prolonged therapy without further assessment should be avoided.
“I wouldn’t keep patients on antacids for more than a month without a specialist opinion.”
He commonly uses omeprazole or esomeprazole, particularly in younger children who need the medication compounded into a suspension. As a guide, he uses 10 mg in children under 20 kg and 20 mg in those 20 kg and over. He also prescribes lansoprazole (Zoton), which is available as an oral dispersible tablet in either 15mg or 30mg doses.
Beyond the urgent red flags above, GPs should consider specialist referral for children with functional abdominal pain when symptoms have not improved after three to six months of first-line management, when pain is causing significant functional impairment (school attendance below 50%, social withdrawal, or cessation of normal activities), or when comorbid anxiety or significant family distress is prominent.
Key takeaways
Paediatric Gastroenterology Victoria (PGV) accepts GP referrals for specialist paediatric gastroenterology assessment, including via telehealth for families around Australia. For children with an elevated calprotectin or positive coeliac serology, PGV’s Rapid Review Clinic provides timely assessment and clear next steps. Referrals can be made at paediatricgastro.com.au or by calling 03 9345 6644.
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