Children Present Differently
Paediatric gut symptoms overlap considerably with adult conditions, but presentation, differential diagnosis, and management differ significantly. Children cannot always articulate their symptoms precisely, growth and development add dimensions absent in adult practice, and some conditions (intussusception, pyloric stenosis, Hirschsprung disease) are uniquely paediatric.
Red Flags That Require Urgent Assessment
Bloody diarrhoea — especially in combination with fever, may indicate IBD, infectious colitis, or haemolytic uraemic syndrome (HUS). Bilious (green) vomiting in a neonate — suggests intestinal obstruction (malrotation with volvulus) until proven otherwise, and is a surgical emergency. Persistent vomiting with failure to thrive — may indicate pyloric stenosis (typically 2-8 weeks old), coeliac disease, eosinophilic oesophagitis, or metabolic disease. Faltering growth (crossing weight or height centiles downward) — a non-specific but important signal that an underlying condition may be impairing nutrition. Weight loss in a child is always concerning and warrants investigation. Perianal disease — skin tags, fissures, or fistulae in children should raise suspicion for Crohn's disease. Abdominal mass — palpable mass requires urgent imaging to exclude intussusception, tumour, or abscess.
Functional Abdominal Pain in Children
Functional abdominal pain (including paediatric IBS) is common — affecting 10 to 20 percent of school-age children. Rome IV criteria for paediatric functional GI disorders provide a positive diagnostic framework. Key features suggesting functional rather than organic disease include: periumbilical pain (rather than localised to specific quadrants), no nocturnal symptoms, normal growth trajectory, no alarm features, and symptom modulation by emotional factors (school stress, family changes). Reassurance, dietary advice, and psychological support are first-line; extensive investigation in the absence of alarm features is generally inappropriate and may reinforce illness behaviour.
Coeliac Disease in Children
Coeliac disease presents differently in children than adults. Classic presentation (chronic diarrhoea, abdominal distension, failure to thrive) is now less common than atypical presentation (iron-deficiency anaemia, short stature, delayed puberty, dental enamel defects). European guidelines (ESPGHAN) allow non-biopsy diagnosis in children with tTG-IgA greater than 10 times the upper limit of normal, positive EMA, and compatible symptoms — avoiding endoscopy in clear-cut cases.
IBD in Paediatrics
Paediatric IBD has unique features: more extensive disease at diagnosis than adult-onset IBD, higher rates of upper GI involvement, growth impairment as a presenting feature, and exclusive enteral nutrition (rather than corticosteroids) as first-line induction therapy for paediatric Crohn's disease. Early diagnosis and aggressive treatment are critical to protect growth and pubertal development.
When to Reassure
Infant colic (excessive crying without organic cause, resolving by 3-4 months), toddler's diarrhoea (loose stools with undigested food in an otherwise thriving child), and functional constipation (common, responsive to dietary modification and behavioural strategies) are benign conditions where parental reassurance and simple interventions suffice.