A Systematic Approach to Management of Abdominal Pain in Preverbal and Nonverbal Children in the Emergency Department

What makes pain assessment different in preverbal and nonverbal children?

These patients are almost entirely dependent on caregivers and clinicians to identify the presence of pain and interpret its quality and severity. Assessment relies on behavioral cues (eg, motor activity, communication patterns, and facial expression) interpreted in the context of the child’s baseline, developmental stage, and any disability.

Which pain assessment tools are available?

No single scale is the gold standard. Self-reported scales suit older, verbal children, while behavioral scales, from neonatal tools to versions adapted for neurodivergent patients, fill the gap, each with defined age ranges, strengths, and limitations to consider when choosing the best fit for the patient.

What role should parents and caregivers have?

Parents know the child’s baseline better than anyone, but they can support or unintentionally hinder the encounter. A structured approach works best: involve the parents at the beginning of the encounter for input on the best approaches to their child, communicate directly with the child without interjection, and then cross-reference the information that was gathered.

When are laboratory studies and imaging indicated?

The threshold for workup differs for verbal and nonverbal children, whose differential is almost always broader. Certain historical and physical examination findings point toward a surgical etiology and should prompt workup, with ultrasound as the first-line imaging modality and computed tomography or rapid magnetic resonance imaging reserved for select situations.

How should pain be managed?

A graduated, step-up approach works best: nonpharmacologic measures and nonopioid analgesics first, escalating to ketamine, opioids, or anxiolytics when pain is not adequately controlled, with the route of administration matched to the patient and family input on the best way to give medications.

CASE 1 — Increased Fussiness in a 14-Month-Old: A well-appearing girl presents after a night of hourly screaming. She winces intermittently during the visit and has dark, sticky stools attributed to spinach. The issue discusses what further assessment is needed when the examination is benign but the history raises questions.

CASE 2 — Fever and Vomiting in a 3-Year-Old: A boy with a flat affect has rebound tenderness and guarding concerning for appendicitis. The surgical resident asks that pain medication be withheld to avoid “interfering with examinations.” The issue explores how to manage his pain while the surgical evaluation proceeds.

CASE 3 — Nonverbal Autistic Boy With Abdominal Pain: An agitated 8-year-old boy presents with dark, foul-smelling urine and lower abdominal pain. His mother shares his sensory preferences and past hospital experiences. The issue considers how to treat the boy’s agitation and pain while preserving patient and parent rapport.

• Differential diagnosis table for abdominal pain in pediatric patients, grouped by age
• Reference table of pediatric pain assessment tools, including suitable patient age ranges
• 5 Things That Will Change Your Practice
• Clinical pathway for evaluation and diagnosis of acute abdominal pain in preverbal and nonverbal children
• Links to online appendicitis scoring tools at MDCalc.com

• Underestimating pain when a child does not exhibit typical pain behaviors
• Rushing the examination instead of incorporating parents’ knowledge of a neurodivergent child’s needs
• Withholding pain medication because of concerns it will interfere with evaluation and diagnosis
• Attributing infant lethargy to a nonabdominal cause without ruling out intussusception
• Examining a patient in a chair rather than a recumbent position and missing conditions requiring intervention