#160: Gut Feelings: Navigating Pediatric Functional Abdominal Pain

November 26, 2025 | By Sam Masur

Audio

In this episode, Dr. Kahleb Graham (Cincinnati) joins us to chew on functional abdominal pain. Together, we explore the GI tract and the many symptoms that can result from poor gut-brain communication! From diagnosis to management, this episode is packed full of digestible insights!

Functional Abdominal Pain Pearls

1. Disorders of gut-brain interaction can be diagnosed clinically and are not considered diagnoses of exclusion. 
2. Functional abdominal pain is a common diagnosis and can be very debilitating for patients, but it is manageable with a multidisciplinary approach.
3. The goal of treatment for DGBIs is to improve function first and reduce symptoms, not to completely eradicate all pain.

Functional Abdominal Pain Notes 

Pathophysiology

Functional abdominal pain falls under the umbrella of disorders of gut-brain interaction (DGBI) which are caused by miscommunication between the two systems. The enteric nervous system controls the speed and direction of movement through the GI tract, the contraction or dilation of the intestine, and the sensory components such as pain, nausea, the feeling of fullness, distention, or bloating. All of these can dysfunction or be overactivated by poor gut-brain communication, therefore leading to a wide range of presenting symptoms. 

Presentation

DGBIs can be related to disorders of either (or both) the motor or sensory modality of the GI tract. This leads to a wide range of presenting symptoms which can be grouped as follows: 

• Irritable bowel syndrome (IBS): more lower tract abdominal pain, with motor symptoms of constipation or diarrhea
• Functional dyspepsia: more upper tract abdominal pain, with sensory symptoms of nausea, satiety, and vomiting
• Functional abdominal pain: isolated chronic pain without motor involvement (no change in bowel patterns)

Incidence/Prevalence

In children, the estimated global pooled presence of functional abdominal pain disorders ranges from approximately 11-13% (Vermeijden et al., 2025, Korterink et al., 2015), with IBS being the most common subtype. Prevalence is higher in girls than boys. 

Differential

Causes of chronic abdominal pain can be grouped into four basic categories:

• Inflammation – such as Celiac disease, IBD
• Infection – such as H. pylori, diverticulitis, chronic pancreatitis
• Anatomy – such as hernias, cysts, endometriosis
• Disorders of Gut-Brain Interaction

Work-Up and Diagnosis

Further History

• Determine chronicity
• Identify triggers
• Associated conditions include anxiety, depression, headaches, POTS, or Ehlers-Danlos Syndrome
• Supporting symptoms of the diagnosis include distractible pain, pain only in certain settings (i.e. school, social settings).
• Red flag symptoms include unilateral pain, growth faltering, dysphagia, odynophagia, blood in stool. Providers may need to pursue further workup if these symptoms are present. 

Screening

Diagnosis can be made just with history, it does not need to be a diagnosis of exclusion. However, common initial testing includes:

• CBC
• CMP
• TTG IgA/total IgA
• Fecal calprotectin
• Stool occult blood

Further Workup

Based on screening tests, may pursue further testing:

• Abdominal ultrasound
• Endoscopy
• Colonoscopy
• KUB (although this is not needed to diagnose constipation)

Treatments

It’s important to emphasize that treatment should be tailored to the patient’s goals, improving function in the settings where they are having difficulty (school, socially, at mealtimes, etc.)  and reducing symptoms to allow for improved quality of life. This treatment will likely require a multi-pronged approach of the below modalities.

Medications

Most medications do not work well for chronic abdominal pain. Dr. Graham recommends starting only one medication at a time, and then stopping if ineffective before trialing another.

Antihistamines: Typically recommend starting cyproheptadine 4 mg BID, and then providers can increase to three times daily dosing.  The dose can be uptitrated as needed, up to 16 mg/day.

TCAs: Most frequently used is amitriptyline. Providers can start with putting the patient on 10-20mg daily, uptitrating within 2 weeks as needed and as tolerated up to 50 mg/day.  However, TCAs can have very significant side effects, such as constipation, blurry vision, weight gain, and cardiotoxicity. These should be monitored for, and it is recommended to get baseline EKG prior to initiating a TCA. Dr. Graham warns against starting a TCA for management of pain if patients are likely to require an SSRI or SNRI for treatment of anxiety/depression due to the risk of drug interactions with polypharmacy. 

SSRIs/SNRIs: While citalopram (an SSRI) is the most commonly used, the data is mixed supporting the use of SSRIs and SNRIs for treatment of chronic abdominal pain. (Ford et al., 2018) There may be a direct contribution of these medications to pain control, but the perceived benefit may also be due to improvement in anxiety and depression. 

Antispasmodics: The most frequently used are dicyclomine and hyoscyamine, typically used more as a PRN medication. 

Gabapentin: Not very frequently used, but can help with chronic pain. Recommend starting patients on daily or BID dosing with 5 mg/kg/dose and can titrate up to 300 mg/dose. 

Anti-nausea/anti-diarrheals: These may be used as needed for symptom management but are not recommended for treatment. Loperamide, for example, was not shown to be significantly different to placebo and was associated with adverse effects. (Ford et al., 2018)

Supplements: Peppermint oil is a natural smooth muscle relaxant that has been shown to have an anti-spasmodic effect but may also worsen reflux leading to worsening of dyspepsia symptoms. (Ford et al., 2018) Two common brands for these supplements are IBgard (ingredients include peppermint and menthol) for lower abdominal tract dysfunction (IBS-C and IBS-D) and FDgard (includes caraway and menthol) for upper abdominal tract dysfunction (functional dyspepsia). 

Dietary Management

As with medications, there is no single diet that is universally effective. Dr. Graham recommends trialing one change, assessing efficacy after several weeks, and then re-introducing that food if no significant improvement. Then a different change can be explored for efficacy.  

Modifications that many patients find effective include reducing or removing:

• Dairy
• Gluten
• Simple sugars
• Processed foods (particularly foods with emulsifiers in them)
• Red meats

Further modifications include:

• Mediterranean-style diet
• Low-FODMAP, however many patients and families find this to be too restrictive to be truly feasible

Added foods that may be helpful include:

• Peppermint oil may be helpful as an anti-spasmodic (see medication section)
• Ginger may be helpful with nausea
• Probiotics have very mixed data, with some studies demonstrating effect but with significant heterogeneity. (Su et al., 2020) Dr. Graham noted that lactobacillus and VSL3 have the most supportive data but still require further research to determine how they should be used to be most effective. (Groen et al., 2025) There is no strong evidence that these are harmful, however, so can be used if patients prefer. 

Non-pharmacologic Interventions

• Psychology/GI Psychology – incredibly helpful measure, often using CBT to help with the pain cycle, guided imagery to focus on reducing anxiety, managing the pain-gate
• Abdominal PT – strengthening core, improve muscle function, relieve tension
• Neuromodulation – stimulating the vagus nerve to desensitize the brain-gut connection (IB-stim)
• Acupuncture

Support for School

These patients may need letters to explain their dietary needs, bathroom accommodations, making sure they are allowed to have water with them to maintain hydration, etc. 

Goal

Listeners will be able to identify the underlying pathophysiology of functional abdominal pain and feel comfortable discussing the diagnosis and management with patients and their families.

Learning Objectives

After listening to this episode listeners will…  

1. Describe the pathophysiology of disorders of gut-brain interaction, including the roles of visceral hypersensitivity, altered motility, and psychosocial factors.
2. Identify and differentiate the clinical presentations of disorders of gut-brain interaction, including irritable bowel syndrome, functional dyspepsia, and functional abdominal pain.
3. Discuss the differential diagnosis for chronic abdominal pain in children, including inflammatory, infections, anatomical, and DGBIs and indications for further work-up to make a final diagnosis. 
4. Outline the range of treatment modalities and feel comfortable developing an approach to management including medications, dietary modifications, patient and family education, and psychological interventions. 

Disclosures

Dr. Graham was previously a consultant for Ironwood and Abbvie pharmaceuticals, All efforts have been made to present balanced information about treatment options.

Citation

Engel S, Campbell T, Graham K, Chiu C, Masur S. “#160: Gut Feelings: Navigating Pediatric Functional Abdominal Pain”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ November 26, 2025.