See also

Chest infection
Increased Seizure

Background

Pay particular heed to concerns of parents or carers about behavioural change. Possible causes include

• Otitis media
• Pharyngitis
• Dental disease
• Gastro-oesophageal reflux
• Urine infection
• Constipation
• Renal stones (increased risk if on Topiramate)
• Subluxating and dislocated hips
• Fractures (including pathological)
• Increased seizures
• Medications
• Gynaecological
• Sleep deprivation (associated with pain and spasm) 
• Spasticity (spasms may cause pain, but are often secondary to pain)
• Increased intra-cranial pressure (many children have VP shunt)
• Consider non-accidental injury (under reported in this group)
• Changes in home environment, school or family

Assessment

The pattern and time course of distress may point to one or more of the above causes. The majority of clues come from a carefully taken history.

• Examine ENT, abdomen, hips, limbs in particular
• Check FWT urine for blood (?stones), white cells (infection?)

Investigations that are sometimes useful

• Hip X-ray
• Gastroscopy
• Abdominal ultrasound or renal CT
• Bone Scan
• CT brain

Consider seeking review by paediatric dentist

Management

• Provide adequate analgesia
• Treat identifiable causes
• If there is no obvious cause after assessment
  • Consider trial of anti-acid medication (eg ranitidine) 
  • Consider trial of laxatives
• Admission may be required for further investigation, or because of degree of distress
• Social work assessment may be useful to evaluate stresses at home and / or to organise support services