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Contextualising Pain

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There are a number of key features that need to be considered in the history taking examination phase. Abdomen pain can be quite common in children but its presentation is the key part for the clinician. It can sometimes be quite easy to spot the true surgical abdomen in children. The very robotic like movements, the look of intense fear on their face but also these very painful abdomens should be considered to be surgical emergencies. Wavelike type pain that comes and goes and persist over a period of time is a very uncommon feature of pain in children and should be taken very seriously. For example, the triad of intussusception.
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An infant child that draws their knees up to their chest, appears very pale and then goes very lethargic after these periods, should be considered a surgical emergency.

When assessing a child with abdominal pain, as with any medical problem in children, you need to take a detailed history and then look at the physical signs; putting these together will help you get the diagnosis (or at least be able to put this child into a big sick or little sick category). In the neonate and very young infant, serious pain may present with a child who either cannot be settled by anyone (but remember there is a bit of a vicious cycle here as sometimes anxiety in parents can result in infants not settling) or who is very pale and quiet.

As the child becomes more verbal it is easier to balance what is being described and what you are seeing. A toddler or younger child with severe pain associated with a possible surgical cause, may be quiet and scared looking or alternatively agitated. What they will not be is distractible. However benign causes of pain such as mesenteric adenitis may present you with a child who, with good interaction and use of distraction, will chat to you and even smile. In the older child you would expect severe pain to have a physiological effect such as tachycardia, although this is not invariable.

It can be difficult to determine the extent of the pain with a very distressed young person but if the reported pain appears out of keeping with physical appearance of the child (a smiling child who tells you that their, ‘Belly’s killing them’) you are likely to be dealing with a much less serious condition.

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Emergency and Urgent Care for Children: a Survival Guide

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