Behind the bellyache: a comprehensive review and the novel SAFE child diagnostic algorithm for abdominal pain in children

Abstract

Abdominal pain is one of the most common presenting complaints in pediatric practice, spanning a spectrum from self-limited functional discomfort to acute surgical emergencies. The diagnostic challenge is compounded in young children by limited symptom articulation, overlapping presentations across organic and functional disorders, and inconsistent application of validated screening criteria in routine practice. This narrative review synthesises current evidence on the epidemiology, classification, etiology, red-flag recognition, and diagnostic and management approach to abdominal pain in children, drawing on clinical practice guidance from the American Academy of Family Physicians, NASPGHAN, and Rome Foundation criteria, and introduces an original structured clinical algorithm  the SAFE-Child Algorithm (Systematic Assessment For Evaluating abdominal pain in Children) unifying triage, age-based differential diagnosis, alarm-symptom screening, and Rome IV functional classification into one stepwise pathway. Acute abdominal pain requires first-pass triage for surgical emergencies (appendicitis, intussusception, malrotation/volvulus, incarcerated hernia) using age-specific differential diagnosis and localizing signs. Chronic or recurrent abdominal pain (RAP), present in up to 19% of children in population-based studies, is functional in the large majority of cases, with an organic cause identified in only 5-10%; a validated alarm-symptom screen and Rome IV criteria allow most children to be confidently classified without unnecessary invasive investigation. The SAFE-Child Algorithm operationalises this evidence into a six-step pathway spanning emergency triage through biopsychosocial management and structured follow-up. A structured, stepwise diagnostic approach can reduce unnecessary investigation in functional abdominal pain while ensuring timely recognition of organic and surgical disease.