Functional dyspepsia (FD) is a disorder with a broad clinical spectrum in children, with manifestations that frequently overlap those of other functional gastrointestinal disorders.

The reported prevalence varies widely due to underdiagnosis and the lack of diagnostic criteria, resulting in a high volume of pediatric specialist visits.

The study of DF is hindered by uncertainty on many aspects. These range from its definition, clinical spectrum, broad differential diagnosis and lack of an optimal test for diagnosis to the absence of treatments with established efficacy among those currently available.

A recently published nationwide survey evinced the considerable heterogeneity in the management of pediatric FD in Spain.1 The aim of the project presented in this article was to develop recommendations for medical providers on the definition, presentation, diagnosis, management and outcomes of DF that could guide the optimization of everyday clinical practice based on the best available evidence.

The first step was forming a group composed of 19 members of the Working Group on Motility and Functional Gastrointestinal Disorders (FGIDs) of the Sociedad Española de Gastroenterología, Hepatología y Nutrición Pediátrica (SEGHNP, Spanish Society of Paediatric Gastroenterology, Hepatology and Nutrition). The group formulated 27 clinical questions regarding the management of FD.

A coordinating group was established to recruit the authors of the document, formulate the initial questions, collect the answers and develop a questionnaire to allow voting on the statements.

The rest of the members were divided into four groups to answer questions regarding the definition, epidemiology, diagnosis, treatment and follow-up of FD.

Each group conducted a search in PubMed and contributed sources for the topics it had to review, and the coordinating group gathered and consolidated the sources, eliminating duplicates, for the subsequent analysis of a total of 113 references to answer the formulated clinical questions (Appendix B). This literature review gave rise to 44 statements that were subjected to a first round of anonymous voting, with six possible answer choices, defining consensus as agreement by 80% or more of voters (A + and A), and reformulating in negative form those recommendations for which 80% or more voters expressed disagreement (C and C+); after which the opportunity was given to offer suggestions on an anonymous basis. After this step, new statements were added to a total of 57, which were subjected to a second round of voting (Appendix B), through which consensus was reached on 32. Last of all, the group held an online meeting in which participants agreed on the 27 recommendations to be issued and the definitive text of the guideline (Fig. 1).

Figure 1.

Flow chart of the steps taken in developing this document.

(0.31MB).

Functional dyspepsia is a clinical diagnosis based the presence of two or more of the following symptoms: postprandial fullness (68%–86%), early satiation (49%–72%), epigastric pain (68%–74%) and/or epigastric burning (35%–75%) not associated with defecation (Table 1).

The Rome IV criteria state that the child must experience at least one of these symptoms more than 4 days per month and have had the symptoms for longer than two consecutive months and that, after appropriate evaluation, the symptoms cannot be fully explained by another medical condition. Other symptoms may also be present, such as epigastric distension (68%–84%), belching (50–60%), nausea (39–65%) or vomiting (23%–31%).2,3

The possible organic causes of dyspepsia to rule out in children include peptic ulcer, gastroesophageal reflux disease, celiac disease, upper gastrointestinal Crohn’s disease, pancreatic or biliary disorders, intolerance to food or drugs, infectious diseases, such as giardiasis, infiltrative diseases, such as eosinophilic gastroenteritis, and systemic diseases.4

The Rome IV committee adopted further classification of FD into two subtypes: postprandial distress syndrome and epigastric pain syndrome,5 although symptoms frequently overlap or even shift from one subtype to another.6

The prevalence of FD is of approximately 5% in school-aged children and adolescents,7 and postprandial distress syndrome is the most common subtype in adolescents.

In addition to genetic predisposition, a history of organic and/or psychosocial trauma can play a role in the development of FD and other disorders of the brain-gut-microbiome axis.8

Disorders like anxiety and depression are reported more frequently in patients with FGID compared to the general population. It is likely that these disorders precede the development of dyspepsia, but causality has yet to be clearly established.3

The diagnosis of FD can be made without performing diagnostic tests if there are no red flags in patients who meet the Rome IV criteria. Red flags require further investigation and include the following: family history of inflammatory bowel disease (IBD), celiac disease or peptic ulcers; persistent abdominal pain in the right upper or lower quadrant; dysphagia, odynophagia, persistent vomiting, gastrointestinal bleeding, anemia; nocturnal diarrhea, arthritis, perianal disease, weight loss; growth delay, delayed puberty or unexplained fever (Table 2).

There is no evidence that bloodwork, esophageal pH monitoring, sonography or gastric emptying scans contribute valuable information to the diagnosis of FD as long as patients do not develop alarm signs or symptoms at a later time.9,10

The Rome IV pediatric committee and the European and North American societies for pediatric gastroenterology, hepatology and nutrition (ESPGHAN and NASPGHAN, respectively)5,10,11 do not consider performance of upper endoscopy necessary for diagnosis of FD, but recognize that local practice patterns and social considerations may influence decision-making.

After reviewing the available evidence, we consider that an upper endoscopy is only required in patients with a previous diagnosis of FD who develop alarm signs or symptoms, and its performance can also be contemplated in patients who do not respond to conventional medical treatment or with symptoms that are so frequent or severe that they have a significant impact on quality of life.

As regards the role of H pylori in FD, the 2024 ESPGHAN guideline on the management of infection by H pylori specifies that testing with the sole purpose of ruling out infection by this pathogen in patients with FD is not indicated except in the presence of alarm symptoms with detection of ulcers and/or erosions on endoscopy,12 noting that non-invasive tests would not be useful in these patients.

The management of FD is based on pharmacotherapy, complementary therapies and psychological support (Table 3).

Psychotherapy, including hypnotherapy, psychodynamic therapy and cognitive-behavioral therapy, have been used in adult patients with FD.26 Few studies have been conducted in the pediatric population.

Hypnotherapy has been found to be highly efficacious for treatment of children with irritable bowel syndrome (IBS) or functional abdominal pain, with success rates ranging from 62% to 85%.27,28

The reported results of acupuncture in patients with FD have been inconsistent,29 while yoga may be beneficial in the management of FD.30 However, the evidence is of poor quality, and rigorous studies are required to determine the impact of these therapies when used alone and when combined with conventional treatment in the pediatric population.

The FD subtypes have different clinical features, so they may require specific therapeutic approaches. However, no recommendations have been defined in either the adult or pediatric populations.

When it comes to PPIs, there is some evidence suggesting that they are particularly efficacious for epigastric pain syndrome,16 although it is not consistent with the evidence from other studies that have not found differences between the two subtypes.13,31

In addition, although some authors have proposed that prokinetics may be more effective in patients with postprandial distress and tricyclic antidepressants for epigastric pain syndrome, the evidence on the subject is scarce,31 and there are only recommendations based on expert opinion21 proposing the preferred use of tricyclic antidepressants or amitriptyline for epigastric pain syndrome or of cyproheptadine or buspirone for postprandial distress syndrome.

If a patient has symptoms of FD and concurrent infection by H pylori, it is likely that the two conditions are independent,32 and not likely that treatment for H pylori will improve the symptoms of dyspepsia.

Based on the evidence currently available for the pediatric population, we cannot recommend the “test and treat” strategy,32 so, as proposed in the ESPGHAN guidelines, H pylori eradication therapy should not be given to patients with FD without endoscopic evidence of pathological involvement (ulcer, gastritis).12

There are no biochemical or imaging markers to measure and monitor the response to treatment, so it is mainly assessed based on the symptoms perceived by the patient.

However, in adult patients, scores and questionnaires may be used for this purpose, and can be classified into two broad groups: scales that allow assessment of the intensity or severity of symptoms, and questionnaires that measure the disease-specific impact of dyspepsia on the quality of life of the patient.

The first group includes the Severity of Dyspepsia Assessment (SODA)7,36 and the Patient Assessment of Upper Gastrointestinal Disorders-Symptom Severity Index (PAGI-SYM),37 which has been validated and translated to Spanish; and, when it comes to the quality of life assessments, the most widely used are the Nepean Dyspepsia Index (NPI), validated in multicenter studies conducted in Europe and the United States,38 and the Glasgow Dyspepsia Severity Score (GDSS),39 both of which have been translated and validated in the Spanish population.

There are no validated questionnaires to assess response to treatment in the pediatric population.

In the absence of red flags, it is possible to make the diagnosis based on the Rome IV criteria and plan the initial treatment (explanation of symptoms, modification of psychosocial factors and diet) at the primary care level. Patients must be referred to a specialist in the case of alarm signs or symptoms or of persistent or severe symptoms resulting in impaired quality of life.

Based on the biopsychosocial model of disease, different expert opinions agree on the need for multidisciplinary management involving gastroenterologists, dietitians/nutritionists, mental health professionals and social workers,2 especially in the case of patients with refractory symptoms.

Based on the presented recommendations, taking into account everyday clinical practice and the low quality of the available evidence, the working group developed two algorithms for the diagnosis, treatment and follow-up of these patients at the primary care and specialty care levels (Figs. 2 and 3) with the aim of standardizing the management of patients with FD.

Figure 2.

Algorithm for the management of functional dyspepsia at the primary care level.

(0.3MB).

Figure 3.

Algorithm for the management of functional dyspepsia in specialty care.

(0.39MB).

This research did not receive any external funding.