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Director-General
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This Policy Directive may be varied, withdrawn or replaced at any time. Compliance with this directive is mandatory
for NSW Health and is a condition of subsidy for public health organisations.
POLICY STATEMENT
PURPOSE
The Infants and children: acute management of abdominal pain clinical practice guideline
(attached) has been developed to provide direction to clinicians and is aimed at achieving
the best possible paediatric care in all parts of the state.
The clinical practice guideline was prepared for the NSW Ministry of Health by an expert
clinical reference group under the auspice of the state wide Paediatric Clinical Practice
Guideline Steering Group.
MANDATORY REQUIREMENTS
This policy applies to all facilities where paediatric patients are managed. It requires the
Chief Executives of all Local Health Districts to have local guidelines / protocols based on
the attached clinical practice guideline in place in all hospitals and facilities required to
assess or manage children with abdominal pain.
The clinical practice guideline reflects what is currently regarded as a safe and appropriate
approach to the acute management of abdominal pain in infants and children. However, as
in any clinical situation there may be factors which cannot be covered by a single set of
guidelines. This document should be used as a guide, rather than as a complete
authoritative statement of procedures to be followed in respect of each individual
presentation. It does not replace the need for the application of clinical judgement to
each individual presentation.
IMPLEMENTATION
Chief Executives must ensure:
Local protocols are developed based on the Infants and children: acute
management of abdominal pain clinical practice guideline.
Local protocols are in place in all hospitals and facilities likely to be required to
assess or manage paediatric patients with abdominal pain.
Ensure that all staff treating paediatric patients are educated in the use of the locally
developed paediatric protocols.
Directors of Clinical Governance are required to inform relevant clinical staff treating
paediatric patients of the revised protocols.
REVISION HISTORY
Version Approved by Amendment notes
December 2013 Deputy Director General, Second edition
(PD2013_053) Population and Public Health
January 2005 Director-General New policy
(PD2005_385)
ATTACHMENT
1. Infants and children: acute management of abdominal pain Clinical Practice Guideline.
This work is copyright. It may be reproduced in whole or part for study or training
purposes subject to the inclusion of an acknowledgement of the source. It may not be
reproduced for commercial usage or sale. Reproduction for purposes other than those
indicated above, requires written permission from the NSW Ministry of Health.
This Clinical Practice Guideline booklet is extracted from the PD2013_053 and
as a result, this booklet may be varied, withdrawn or replaced at any time.
Compliance with the information in this booklet is mandatory for NSW Health.
December 2013
A revision of this document is due in 2016.
Contents
Introduction................................................................................................. 2
Changes from previous clinical practice guideline.................................... 3
Overview...................................................................................................... 4
Initial management of the child with acute abdominal pain...................... 5
Abdominal pain algorithm - management of acute abdominal pain in
children........................................................................................................ 6
Background on questions asked in the flowchart..................................... 8
When and how should I relieve the pain?................................................................ 8
Is there evidence of trauma?.................................................................................... 8
Is there a likely acute surgical problem (surgical abdomen)?..................................... 9
Is there any diarrhoea?.......................................................................................... 10
Does the stool contain blood?............................................................................... 11
Does the child have a urinary tract infection?......................................................... 11
Is the problem outside the abdomen?.................................................................... 11
Is the child constipated?........................................................................................ 11
Consultation, escalation, retrieval and transfer issues............................ 12
Less common diagnoses.......................................................................... 13
Other questions in the diagnosis and management
of abdominal pain.................................................................... 15
Appendices
Appendix 1 References....................................................................................... 16
Appendix 2 Resources......................................................................................... 18
Appendix 3 Parent information........................................................................... 19
Appendix 4 Expert working group membership................................................... 20
NSW Health Infants and Children Acute Management of Abdominal Pain PAGE 1
Introduction
PAGE 2 NSW Health Infants and Children Acute Management of Abdominal Pain
Changes from previous clinical
practice guideline
NSW Health Infants and Children Acute Management of Abdominal Pain PAGE 3
Overview
A child presenting with abdominal pain surgical advice available within the
may be suffering from any of a wide range facility of presentation.
of conditions. Most will be benign and
managed by the Emergency Department If a paediatric specialist is not available
Paediatric specialists would prefer to be
staff, paediatricians and general surgeons. or there is a need for higher escalation,
called too early rather than too late.
However the small percentage of Call NETS hotline: 1300 36 2500
children with a condition that may
require surgical intervention and/or be Paediatric Specialist means a local or
life-threatening need to be treated regional paediatrician and/or paediatric
with greater urgency than adult surgeon experienced in managing
patients with equivalent conditions paediatric surgical patients. Such
because they often have fewer consultation is recommended throughout
physiological reserves. The Surgery for this document (in some hospitals
Children project has sought to emphasise consultation may be done through their
urgency and rapid escalation through the registrars).
provision of template Emergency
If such a specialist is not available, call the
Department algorithms.
Newborn and paediatric Emergency
The assessment of a child with a possible Transport Service (NETS) Hotline:
complaint of acute abdominal pain may be 1300 36 2500. The paediatric specialist
challenging to the doctor or nurse who involved may also decide to escalate to
first sees the patient, if they primarily see NETS. NETS will set up a conference call
adult patients. In the pre-verbal child, the which includes a paediatric surgeon and
presence of abdominal pain can only be other relevant paediatric specialists as well
inferred from the childs behaviour and/or as organise urgent transfer of a child to a
from distension and/or tenderness on paediatric centre if necessary.
examination.
Calls to NETS are voice recorded and form
If in doubt or unclear about a childs part of the NETS medical record for the
clinical condition, signs or symptoms, patient.
consult with someone more
NETS may also involve local retrieval teams
experienced, such as a paediatrician or
and other relevant clinicians in the
paediatric surgeon, in addition to the
conference call.
PAGE 4 NSW Health Infants and Children Acute Management of Abdominal Pain
Initial management of the child with
acute abdominal pain
The assessment of the child with possible abdominal pain should follow the pattern of:
1. Primary survey
Airway
Breathing
Circulation
Disability
Exposure
Fluids
Glucose
NSW Health Infants and Children Acute Management of Abdominal Pain PAGE 5
Abdominal pain algorithm - management of acute
PAGE 6
abdominal pain in children
No
Surgical abdomen
No
Immediate referral to paediatrician and
Bloody stool Yes consult with a paediatric surgeon as
required
No
No
Consider gastroenteritis.
Diarrhoea + Vomiting + Fever Yes
(See gastroenteritis guidelines)
No
No
Firm stool palpable in lower abdomen Yes Consider constipation (see text)
No
No specific diagnosis
PAGE 7
Background on questions asked in
the flowchart
PAGE 8 NSW Health Infants and Children Acute Management of Abdominal Pain
history inconsistent with the childs Does the child have any
clinical findings. indicators of intestinal
If non-accidental injury is suspected, child
obstruction?
protection history for the child and family (i) Is there bile-stained vomiting?
should also be checked. Refer to policy
directive on Child Wellbeing and Child This means a definite green colour in the
Protection http://www0.health.nsw.gov. vomit. Sometimes gastric contents can have
au/policies/pd/2013/pdf/PD2013_007.pdf a yellow tinge. This is not bile staining.
Bile-stained vomiting means
NSW Health Infants and Children Acute Management of Abdominal Pain PAGE 9
intervention is more often required for bowel sounds absent / decreased
adhesive bowel obstruction associated non-specific signs
swellings at the site of hernial orifices tachycardia, fever.
and of the external genitalia.
Symptoms and signs of acute abdominal
pathology may be masked by an altered
Is there any diarrhoea?
level of consciousness / the presence of
Copious amounts of loose stools suggest shock. Repeat examination after
gastroenteritis but do not exclude other resuscitation or an appropriate interval.
conditions (eg intussusception, pelvic
appendicitis, pelvic abscess and Is there a palpable abdominal
inflammatory bowel disease). mass?
NB: Gastroenteritis consists of the Examination of an abdominal mass should
triad of vomiting, diarrhoea and focus on: site, mobility, tenderness,
fever.8 potential relationship to the intestine,
mesentery, liver, spleen, pancreas, kidneys
Does the child have other or pelvic organs. Examples of conditions
abdominal tenderness? with abdominal masses include
This is tenderness not associated with intussusception (sausage shaped) or
peritonitis. Is the tenderness located in the neoplasm (eg neuroblastoma),
abdominal wall or the abdominal cavity? Is appendicitis, Crohns disease.
it localised or generalised?
Is there inguino-genital pain or
Does the child have peritonitis? swelling?
Signs consistent with peritonitis include:
(i) Is there an irreducible inguinal hernia?
refusal / inability to walk
The inguino-genital region should always
slow walk / stooped forward
be examined in a child presenting with
pain on coughing or jolting abdominal pain. An irreducible inguinal
lying motionless hernia is a surgical emergency and if
decreased / absent abdominal wall suspected, a paediatric or experienced
movements with respiration adult surgeon should be consulted
abdominal distension immediately.
PAGE 10 NSW Health Infants and Children Acute Management of Abdominal Pain
experienced adult surgeon should be the specimen must be sent for urgent
consulted immediately. An immediate microscopy and culture.
local procedure may be indicated.
A urinary tract infection should be treated
with appropriate antibiotics and
Does the stool contain blood?
appropriate follow up arranged for the
Blood mixed with stools may indicate patient with a paediatrician.
infective diarrhoea. The presence of
blood makes it more likely to be Is the problem outside the
bacterial. Ask about travel history and
abdomen?
recent antibiotic therapy
(pseudomembranous colitis). The chest is not far from the abdomen in
children. A lower lobe pneumonia or acute
Blood mixed with mucus (redcurrant
heart failure should be considered if there
jelly) suggests intussusception.
is fever, cough, tachypnoea, desaturation
Altered blood (melaena) suggests or consistent clinical signs. Consider a
upper gastrointestinal bleeding. chest X-ray. (NB auscultatory chest signs are
often absent in pneumonia in childhood).
Other conditions where there can be
abdominal pain associated with blood in
the stools include:
Is the child constipated?
Inflammatory bowel disease Constipation is defined as the progressive
accumulation of hard faeces within the
Midgut volvulus (shocked child)
rectum associated with increasing
Henoch schonlein purpura difficulty and ultimate failure of the
Haemolytic uremic syndrome. passage of stool.
NSW Health Infants and Children Acute Management of Abdominal Pain PAGE 11
Consultation, escalation, retrieval
and transfer issues
PAGE 12 NSW Health Infants and Children Acute Management of Abdominal Pain
Less common diagnoses
Does the child have a known Strongly consider a serum beta HCG to
congenital or pre-existing exclude pregnancy (CONSENT REQUIRED).
condition that may be related to
the abdominal symptoms and Could there be other
signs? gynaecological problems?
As part of the assessment contact the If history and physical examination are
childs treating specialist to discuss consistent with possible gynaecological
treatment options. problem, refer to a consultant
gynaecologist.
Is there jaundice?
Has the child been poisoned or
Hepatitis may present with pain due to envenomed?
liver swelling. Rarely children may have a
painful obstructive jaundice (e.g. Many toxic agents and some
choledochal cyst or gallstones). envenomations will cause abdominal
symptoms. Some can cause acute
Is the child feeding normally? abdominal pain (e.g. iron). It is important
to ask about a history of possible ingestion
Poor feeding is a non-specific indicator of and what drugs and other toxic agents are
serious illness. available at home. Some agents will cause
characteristic syndromes called toxidromes
Is the patient a post-menarchal (e.g. anticholinergics), while others can be
female? measured in the blood (e.g. paracetamol,
lithium). It is also important to ask about
Has the adolescent started her periods? If possible bites and stings. Knowledge of
so when was the last normal menstrual the local venomous creatures is necessary.
period?
Ring the NSW Poisons Information Centre
Is she sexually active? (Ask the patient on on 13 11 26 24 hours a day, 7 days a
her own. Be aware that there may be a week.
reluctance to disclose).
NSW Health Infants and Children Acute Management of Abdominal Pain PAGE 13
Is there a rash?
Scarlet fever, enteroviruses, Henoch
Schonlein Syndrome (HSS) and many other
conditions can cause rashes and acute
abdominal pain.
PAGE 14 NSW Health Infants and Children Acute Management of Abdominal Pain
Other questions in the diagnosis and
management of abdominal pain
When is it necessary to do a
rectal examination?
An inspection of the anal and perineal
area should be performed, looking for
signs of infection, fissures or worms,
among other things. Rectal examination
should not be performed without first
consulting the appropriate surgeon who
may wish to perform it themself to
minimise distress to a child.
NSW Health Infants and Children Acute Management of Abdominal Pain PAGE 15
Appendices
Appendix One References
1. Thomas SH. Silen W. (2003) Effect on 7. NICE Guidance (August 2007) CG54:
diagnostic efficiency of analgesia for Urinary tract infection in children:
undifferentiated abdominal pain. BJ diagnosis, treatment and long-term
Surgery; 90(1):5-9. management.
2. Attard AR, Corlett MJ, Kidner NJ, Leslie 8. NSW Health(2010) PD2010_009
AP, Fraser IA. (1992) Safety of early Infants and children: Acute
pain relief for acute abdominal pain. Management of Gastroenteritis (third
BMJ 305:554-556. edition) Clinical Practice Guideline.
3. The Royal Childrens Hospital 9. Radzik D, Zaramella C. (2007) Early
Melbourne Clinical Practice Guideline analgesia for children with acute
http://www.rch.org.au/clinicalguide/ abdominal pain: Is it applicable
cpg.cfm?doc_id=5036 (Accessed 20 without affecting diagnostic accuracy?
Oct 2008) Acute Pain;9(1):48-49.
4. Scholer SJ, Pituch K, Orr DP, Dittus RS. 10. Herd DW, Babl FE, Gilhotra Y, Huckson
Clinical outcomes of children with S, PREDICT group (2009). Pain
acute abdominal pain. Pediatrics management practices in paediatric
1996;98:680-685. emergency departments in Australia
and New Zealand: A clinical and
5. North American Society for Pediatric
organizational audit by National Health
Gastroenterology Hepatology and
and Medical Research Councils
Nutrition. (2006) Evaluation and
National Institute of Clinical Studies
Treatment of Constipation in Infants
and Paediatric Research in Emergency
and Children: Recommendations of
Departments International
the North American Society for
Collaborative. Emergency Medicine
Pediatric Gastroenterology Hepatology
Australasia 21(3):210221.
and Nutrition. J Pediatr Gastroenterol
Nutr;43;e1-e13. 11. Borland ML, Jacobs I, Geelhoed G.
(2002) Intranasal fentanyl reduces
6. Achong DM, Oates E, Harris B. (1993)
acute pain in children in the
Mesenteric lymphadenitis depicted by
emergency department: A safety and
indium 111-labelled white blood cell
efficacy study. Emergency Medicine:
imaging. J Pediatr Surg 28:1550-1552.
14(3):275280.
PAGE 16 NSW Health Infants and Children Acute Management of Abdominal Pain
12. Cole J, Shepherd M, Young P. (2009)
Intranasal fentanyl in 13-year-olds: A
prospective study of the effectiveness
of intranasal fentanyl as acute
analgesia. Emergency Medicine
Australasia: 21(5):395400.
13. Borland ML, Clark L, Esson (2008) A.
Comparative review of the clinical use
of intranasal fentanyl versus morphine
in a paediatric emergency department.
Emergency Medicine Australasia;
20(6): 515520.
14. National Institute of Clinical Studies
Emergency Care Community of
Practice (2008) Pain medication for
acute abdominal pain: A summary of
best available evidence and
information on current clinical practice;
Emergency Care Evidence in Practice
Series
NSW Health Infants and Children Acute Management of Abdominal Pain PAGE 17
Appendix Two Resources
More information may be necessary in practice, especially for the management of children
with abdominal pain. Possible sources include:
NSW Ministry of Health CIAP web site, PEMSOFT - Acute Abdominal Pain:
http://pemsoft.ebscohost.com.acs.hcn.com.au/contentUK/confirm.html
Kilham ,H.,Alexander,S., Wood N., & Isaacs D.,(2009) Paediatrics Manual: The Childrens
Hospital at Westmead Handbook, (Second Edition) http://chwh.hcn.com.au/index.php
NSW Health (October 2008) Paediatric Surgery Model for Designated Area Paediatric
Surgical Sites
http://www.archi.net.au/documents/resources/hsd/surgery/predictable_surgery/
paediatric-surgery.pdf
NSW Health (March 2007) GL2007_006 Snakebite and Spiderbite Clinical Management
Guidelines found at http://www.health.nsw.gov.au/policies/gl/2007/GL2007_006.html
NSW Health (June 2010) PD2010_031 Inter-Facility Transfers of Children and Adolescents
Clinical Practice Guidelines found at:
http://www.health.nsw.gov.au/policies/pd/2010/pdf/PD2010_031.pdf
PAGE 18 NSW Health Infants and Children Acute Management of Abdominal Pain
Appendix Three Parent Information
An Abdominal Pain (Stomach Ache) Fact Sheet has been jointly developed by The Childrens
Hospital at Westmead, Sydney Childrens Hospital, Randwick and Kaleidoscope Hunter
Childrens Health Network and is available at:
http://kidshealth.schn.health.nsw.gov.au/fact-sheets/common-illness/abdominal-
pain-stomach-ache
http://www.sch.edu.au/health/factsheets/joint/?abdominal.htm
http://www.kaleidoscope.org.au/docs/FactSheets/AbdominalPain.pdf
NSW Health Infants and Children Acute Management of Abdominal Pain PAGE 19
Appendix Four Expert working group membership
PAGE 20 NSW Health Infants and Children Acute Management of Abdominal Pain
SHPN (NKF) 130040