Why Does My Child's Stomach Hurt?

Dr. Richard So, MD:

Welcome to Little Health, a Cleveland Clinic Children's podcast that helps navigate the complexities of child health one chapter at a time. In each session, we'll explore a specific area of pediatric care and feature a new host with specialized expertise. We'll address parental concerns, answer questions, and offer guidance on raising healthy, happy children. Now, here's today's host.

Dr. Senthilkumar Sankararaman, MD:

Welcome to Little Health, where incorporating small steps can lead to big changes. Today's title is, Why Does My Child's Stomach Hurt? When Your Child says, my belly hurts, or my stomach hurts, how do you know if it is just gas or your simple viral infection or something serious that you have your reason to call your doctor? That worry is real and the uncertainty can feel often overwhelming. I'm your host, Dr. Senthil Sankararaman, your pediatric gastroenterologist at Cleveland Clinic Children's, and we kick off our season of Little Health on pediatric gastroenterology issues. We are going to talk about one of the most common issues parents face, kids and stomach troubles. For this podcast, our guest today is my friend and colleague, Dr. Ben Freiberg, your pediatric gastroenterologist at Cleveland Clinic Children's, and Director of Neuro Gastroenterology and Motility program. Welcome to Little Health, Dr. Freiberg.

Dr. Ben Freiberg, MD:

Thanks for having me. Glad to be here.

Dr. Senthilkumar Sankararaman, MD:

For our listeners to, to try to understand you a little better, could you tell us about your background? Where did you bond, where did you grow up, things like that.

Dr. Ben Freiberg, MD:

So I'm an East Coaster through and through. I grew up in uh, Boston, born there, raised there. Um, loved the Red Sox, go Sox, um, and was there through med school. Finally left the Boston area for New York for my residency program. Um, following my pediatric residency, I went to Yale to do, uh, pediatric GI. While I was there, we actually had a new section chief and uh, he turned to me, he asked me, what do you wanna do with yourself? I said, I wanna do advanced endoscopy. No, you don't. What do you mean? No, you don't. <laugh>, I, I love procedures. I love, no, no, no, you, you trust me. You don't wanna wake up in the middle of the night coming in for these complex cases and everything. Stick with me, do a little motility. I'm like, okay, fine. Stuck it out, loved it. And now came here to Cleveland. Uh, been here for four or five years and been doing motility ever since.

Dr. Senthilkumar Sankararaman, MD:

We are so happy to have you here and we are lucky. What attracted you towards Cleveland?

Dr. Ben Freiberg, MD:

Well, it had a job that was <laugh>, uh, but really it, it was a whole bunch of things. So I loved the Midwest atmosphere here. It's definitely not like the east coast where everyone's on top of you. It's very friendly. Um, the weather here, yeah, it can snow, but you know what, it's definitely not as humid over the summer months and the metro parks in Cleveland. Oh my gosh, I love going on, uh, on uh, trips there and doing hiking in the metro parks here.

Dr. Senthilkumar Sankararaman, MD:

So let's dive into the discussion. So stomachache, how common is that in children?

Dr. Ben Freiberg, MD:

It is very common. It's one of the most common things we see. I think uh, about a quarter of all pediatrics visits is about belly pains and about half of all GI visits, pediatric GI visits is gonna be belly pains. So it's very common and I'm sure a lot of these don't even make it to the pediatrician or to general GI, where a lot of times thankfully the parents and the child can manage on their own.

Dr. Senthilkumar Sankararaman, MD:

And what are the common reasons a child can have belly pain?

Dr. Ben Freiberg, MD:

Yeah, so there's a whole host of reasons. Usually the reasons are gonna be very benign, very non-concerning. So a lot of times it'll be after an illness, so a GI bug, an upper respiratory infection, things like that, that it can definitely cause a little disturbance within the GI tract. The foods that will often eat will cause some discomfort, whether it's some spicy food or acidic food or just something that just doesn't sit right in us. And then we'll often talk about like that nervous or anxious stomach as well where you know, you have a big test coming up or you have a big paper that's due. But I find that even just being excited or happy about something can even cause some of those butterflies. And then of course we always have to think about some of the more scary things like true GI illnesses that uh, cause a lot of inflammation within the GI tract and might have to be long-term therapies for that.

Dr. Senthilkumar Sankararaman, MD:

Could you help us understand like say your child is crying due to belly pain, how parents can approach that, whether this pain is from one of the simple things or or simple like um, causes versus more concerning such as like an appendicitis or something similar to it.

Dr. Ben Freiberg, MD:

Absolutely. So I think the first thing to do is you know your child best and if they are showing symptoms that are out of proportion for what they typically will demonstrate, then that should definitely raise some red flags and you should bring it to the attention of your pediatrician or your physician and kind of get a sense. Definitely there are gonna be other factors that can play in. So if your child has a fever, if your child is throwing up and not staying hydrated, those are definitely gonna be things that you'll want to get addressed very urgently, bringing them to urgent care to the emergency room. But if it's kind of a baseline, you know your kid, this seems to be okay. Definitely providing them with some comfort, some reassurance.

Dr. Senthilkumar Sankararaman, MD:

That's good to hear. Thank you. The other question we often get from parents is, is it something related to diet? Is diet causing pain and oftentimes like dairy or gluten, so those kind of foods are often blamed. What is your take on that?

Dr. Ben Freiberg, MD:

Absolutely. Foods can definitely have an impact on belly pain. So there's a lot of people out there that have a lactose intolerance where they eat dairy and because they can't process the lactose, the sugar that's found in dairy, then I like to say the natural microbiome and the GI tract is throwing a party, but that means that produces a lot of gases and things like that that can cause discomfort. Similarly, individuals might have celiac disease that if they eat gluten, that's actually causing an inflammatory issue within the GI tract and that inflammation can lead to a lot of the pain that they'll experience. But putting those aside, just every individual, they just might be a little bit more sensitive to certain foods. So as long as you're not having any sort of inflammatory reason to avoid the food, what I typically say at the end of the day, if you enjoy that cheesecake, if you enjoy that pizza and you know it's gonna cause you a little belly pain but you really want to have it, enjoy it. But for sure if it's going to prevent you from doing the activities that you want to do, maybe avoid it. And definitely if it is something like celiac disease where it is causing inflammation, for sure avoid it.

Dr. Senthilkumar Sankararaman, MD:

Is there a test that your doctor can do to, to look for or to identify celiac disease?

Dr. Ben Freiberg, MD:

Absolutely, yes. So we'll start off with some blood work screening. Um, before that even we'll get a comprehensive history as well if there's any family history for celiac disease or for an autoimmune problem like a thyroid disease that might clue us in. But we'll get some blood work and if it tests positive on the blood work, then we will discuss about doing an endoscopy to confirm the diagnosis.

Dr. Senthilkumar Sankararaman, MD:

So switching gears a little bit, so many, many years ago when I was young, my grandmother, when I say that my tummy hurts, my grandma will say Go and poop. So my question to you is, does constipation cause belly pain?

Dr. Ben Freiberg, MD:

Absolutely, yeah, we'll definitely see lots of kids that are constipated and might not even recognize that they're constipated. Um, I think that's definitely a good thing to try to do, especially if you know the belly pain will improve after bowel movement. Try to have them sit on the potty for a few minutes, try to have a bowel movement and hopefully that will resolve it.

Dr. Senthilkumar Sankararaman, MD:

Yeah, as we all know, a lot of things in stomach, a lot of organs we have in stomach, a lot of conditions can cause or lead to belly pain As expert in this field, how do you sort out the patients who come with recurrent or frequent belly pain, they're having one of those less concerning issues versus something more concerning such as celiac disease or inflammatory bowel disease or other inflammatory conditions?

Dr. Ben Freiberg, MD:

Yeah, and that's actually a big question that I'll get asked, like how do you know it's not something scary that's going on? And the sensory nerves in our GI tract, they're not like the sensory nerves in our skin where it can tell you exactly where things are, whether it's this part of your arm, that part of your leg, it's never going to be, oh, it's this part of my small intestine, that part of my colon, my liver, my kidney. So it is, you know, trying to gather the whole story, what part of the belly is aching, are there any associations, are there things that make it worse, things that make it better, are there nighttime symptoms? Are there other red flags such as weight loss or blood in the stool? Things like that. And for sure if there are any red flags make, making sure that we do screen. So starting off with some of the labs, some of the blood work that we're not missing anything and if everything comes back very much reassuring, providing the family with that reassurance and trying to find steps moving forward to help manage that belly pain so that it's not affecting your child's day-to-day life.

Dr. Senthilkumar Sankararaman, MD:

That's, that's good to, good to hear from you. Does the location of pain, does it help as your doctor to kind of sort out like this leads to suspicion of this condition versus other?

Dr. Ben Freiberg, MD:

Absolutely. So like I was saying, the GI tract can't pinpoint what organ the pain is located in, but based on kind of the general location, so if it's in the lower right side of your belly and in its acute pain with fever, then we'll have a high suspicion for appendicitis because that's where the appendix lives kind of similarly, um, if it's in the upper right part of your belly, um, then we might be thinking about the liver or the gallbladder and other organs. If it's, you know, having some radiation to the back because the kidneys live in the back, we might think kidney outside of the GI tract. But yeah, absolutely based on location it might clue us in on, on where some of that pain might be originating.

Dr. Senthilkumar Sankararaman, MD:

The next question, as pediatricians this question makes all of us very proud. So oftentimes my friends who treat adults ask me, how do you know if your baby or toddler or a nonverbal child has pain? Like for, since we are discussing stomach pain here, like how do you, how do you evaluate or how do you know, do you relay on the history from parents or are there any cues that points towards your stomach pain and kids who cannot express that they have stomach pain?

Dr. Ben Freiberg, MD:

Yeah, you're, you're absolutely right, you know, it's, it's one of the toughest things in pediatrics A lot of times the patient can't talk to, you can't relay any of this and you are relying a lot on the history and other associations. So is this pain or discomfort? Is it coming when the child is eating? Is there maybe not having a bowel movement in the past couple of days? Is there a fever, is there a rash? Other things that might clue us in and for sure the physical exam as well. Is the belly nice and soft or is it very tense or anytime I try to come near the belly, is it really hard and really painful whenever I touch it? Those sorts of things can clue us into something that might be a little bit more scary versus a benign exam where the belly is nice and soft and they are very playful and interactive during the exam that it might be, uh, something a lot more benign.

Dr. Senthilkumar Sankararaman, MD:

And I would add to that the wonderful training we all received during our, our residency and our fellowship and our experience kind of definitely helps us to kind of approach those issues, right?

Dr. Ben Freiberg, MD:

Absolutely. We see a lot of these kids so we get to know it, but again, you know, the, the parents, you, you know your child the best so you can help clue us in as well.

Dr. Senthilkumar Sankararaman, MD:

Yeah, it's a combination of the best of both. Right. So there are other, uh, term we often hear is functional abdominal pain. Could you help us understand what exactly it means?

Dr. Ben Freiberg, MD:

Absolutely. So there's this broad category of disorders of gut brain interaction that you might start hearing or DGBIs that it really comes down to how the nerve endings are operating, how the nerve endings are functioning, that a lot of times those nerve endings can be very hypersensitized where a typical individual on the streets they might experience for the same a situation, uh, on a pain scale of one to 10, they might experience it as a one or a two where somebody else might experience it as a six or a seven. Really what that is, is that the threshold for those nerve endings has gotten knocked down. So that same amount of stimulation is causing those nerve endings to fire and that sends a signal to the brain saying, hey, something is going on and it can really fire off some of those alarm centers. Another way I like to describe it, I know a lot of people out there have heard about fibromyalgia, so I like to describe it's like the fibromyalgia of the GI tract where those nerve endings are firing off at a much earlier time point causing a lot of these pain signals and it can be very distressing.

Dr. Senthilkumar Sankararaman, MD:

And, and also along those lines, I often hear from many people that the child does not want to go to school that's the reason coming and telling us that uh, he or she having belly pain. Do you think that also could be like one of the reasons or is it your real pain?

Dr. Ben Freiberg, MD:

For sure. I do believe that the pain is very much real and you know, different people are gonna have different perceptions of pain and like I was describing before, one individual might say, you know what, I can tough through this and get through the day. Whereas another person, it can really knock them out. So I would not discount any child that says I'm in pain, I'm in, I'm, I can't do this, I can't do that because of the pain. Having said that, I would encourage family members parents to make sure that their kids do attend school, that they try to have as normal of a day-to-day activity because a lot of times that normal activity can help some of those nerve pathways, that it distracts the brain from getting those alarm signals and and really can help soothe things. So yes, I would, I would definitely say the pain is real, but I would, as best as you can encourage your child to do their day-to-day activity.

Dr. Senthilkumar Sankararaman, MD:

Is there a relationship between stress and belly pain?

Dr. Ben Freiberg, MD:

Absolutely. So a lot of times we'll have that nervous stomach, that anxious stomach a test coming up or a paper that's due. But I would say it's really more changes in emotions where we're going to Disney, we're going to see grandma and grandpa, it's Christmas, you're gonna get so many presents. It really is those change in emotions where just because your kid isn't anxious or nervous and that they're going to be doing something fun, exciting doesn't mean that they can't have the belly pain.

Dr. Senthilkumar Sankararaman, MD:

So let's talk about how a parent can approach the pain. Are there any over the counter medications that are safer and effective that parents can try for tummy issues?

Dr. Ben Freiberg, MD:

The first thing, as we talked about earlier, you know, make sure that they're not having any sort of scary features, so make sure they're not having the fevers, the tense belly, things like that that would, would really want you to bring them in to get evaluated sooner rather than later. But if this is just a kid that you know has belly pain every now and then and is otherwise healthy, growing, gaining weight, they're definitely some over the counter tricks that I like to recommend. So one of the biggest ones I would say is peppermint and ginger products. So whether it's peppermint tea, ginger tea, real gingerale, none of the sugary type brands that are out there. Even something as simple as like a peppermint gum that they can kind of chew on that can help really soothe the belly and then, you know, pay attention. Are they having other symptoms like are they having heartburn symptoms? So maybe using a tums for that or if they're having constipation, then starting them on a bowel regimen with the aid of your pediatrician to make sure that they are pooping more regularly.

Dr. Senthilkumar Sankararaman, MD:

So earlier when we discussed, you did mention about the relationship between infection and getting recurrent belly pain, say like, um, often, uh, for various reasons kids also get antibiotics for certain bacterial infections. Does that affect the gut? Is there anything parents can try to do to minimize the impact of antibiotics on child's health?

Dr. Ben Freiberg, MD:

Absolutely. So we know these antibiotics, they are going after the infection that's affecting your child, such as an ear infection or pneumonia or things like that. But it's going to be affecting other organs in the body too. It's gonna be going after all the bacteria within the body that it targets. So it can definitely have an impact on the microbiome within the GI tract, just that natural bacteria that lives in our GI tract. So it might inadvertently change the balance of, you know, less good bacteria, which means it an increase in some of the more bad bacteria that might able to to get a hand over everything. So a lot of times we might recommend using a probiotic while you're using the antibiotic. So that's definitely something that you should discuss with your pediatrician to see if it's worthwhile while your child is on an antibiotic to do.

Dr. Senthilkumar Sankararaman, MD:

Thank you Dr. Freiberg. Those are all so helpful. Good, good points to to remember. Um, the other question I have is, we all know diet is very important, especially more for infants and younger children. What are the ways parents can enrich the quality of the diet for their children?

Dr. Ben Freiberg, MD:

Yeah, and that's something that I'll get a lot of questions about where, you know, the typical American diet, it unfortunately it can be fast food, heavy, um, lots of fatty foods, high calorie foods, um, the sodas, things like that. So as best as you can, I would try to go for a more natural diet. So going for the fruits, the vegetables, the colorful, um, things, not the unnatural, colorful things to be fair. <laugh>. Yeah, and, and also simple things like try to incorporate a little bit more fiber into the diet. So things like whole grain breads, whole grain pastas, brown rice, that can really help with the constipation issues, which might impact some of the belly pain. Um, but at the end of the day, really as long as everything's been checked and there's nothing scary going on, none of these foods are gonna cause harm or damage. So at the end of the day, if your kid wants to have that candy, wants to have that cake and you know, they might have some belly pain, they're gonna enjoy it, it's their birthday, they're out with friends, let them have a little bit, but if it's really gonna cause them distress, maybe avoid.

Dr. Senthilkumar Sankararaman, MD:

Thank you. Thank you so much. It seems like I learned a lot from you Dr. Freiberg. Let's switching gears a little bit more lighter questions. Sure. What is your most favorite sport and um, your most favorite team?

Dr. Ben Freiberg, MD:

<laugh>? Well, as I alluded to before, I am definitely a Boston fan, so, you know, I do really enjoy baseball and, uh, football. So the Red Sox, the Patriots, I'm gonna be rooting for my Celtics, my Bruins. So, um, the Revolution for, uh, football, for soccer, <laugh> as we call it here in the States.

Dr. Senthilkumar Sankararaman, MD:

I'm hoping things will change as you are staying longer and longer here in Cleveland.

Dr. Ben Freiberg, MD:

Uh, we'll have to see, you know, if, if, if the teams are playing a New York team, for sure, I'm gonna root for the local team here, but if they're playing a Boston team, I'm, I'm sorry, Cleveland fans. I'm, I'm gonna be rooting for my hometown [Yeah.] Boston team.

Dr. Senthilkumar Sankararaman, MD:

I'm going to bet on, bet on this. Okay. Um, so the other question is, um, tell us about one of the places your most favorite places you ever visited.

Dr. Ben Freiberg, MD:

Yeah. So are you talking about in Cleveland or anywhere?

Dr. Senthilkumar Sankararaman, MD:

Anywhere. Anywhere, yeah.

Dr. Ben Freiberg, MD:

Ah, so I personally, I love to travel, um, and for our honeymoon we went to Portugal and it was just, it was so wonderful to go to visit all the different towns, Lisbon, Porto, the Algarves. I would say that's one of the most memorable times that I've had.

Dr. Senthilkumar Sankararaman, MD:

Thank you. And since you mentioned Cleveland, um, anything in Cleveland you could tell us?

Dr. Ben Freiberg, MD:

I love the Metro Parks, so I'm a big outdoors person, so on weekends when I'm free, I love to go out, find a new metro park and go hiking.

Dr. Senthilkumar Sankararaman, MD:

Yeah, no, I agree with you. Yeah, it's wonderful. And we are so lucky to have Metro parks here.

Dr. Ben Freiberg, MD:

Absolutely.

Dr. Senthilkumar Sankararaman, MD:

Thank you so much for all your insights and helpful hints. Um, thank you so much coming to our studio.

Dr. Ben Freiberg, MD:

Yeah, thanks for having me here.

Dr. Senthilkumar Sankararaman, MD:

Thank you so much listeners for listening to this podcast. While tummy troubles are very common in childhood, many can be managed successfully. As Dr. Freiberg alluded with simple and consistent steps. Keep your hopeful mindset very optimal, open-minded mindset and know that every small step toward understanding your child's symptom is your step toward your happier, more comfortable life for you and also for them.

If you would like to schedule an appointment with Cleveland Clinic Children's, um, to see one of us in pediatric gastroenterology, please do call us at 216.444.KIDS. It's 216.444.KIDS or 216.444.5437. Thank you again.

Dr. Richard So, MD:

Thanks for listening to Little Health. We hope you enjoyed this episode. To keep the little health tips coming, subscribe wherever you get your podcasts or visit clevelandclinicchildrens.org/little-health.