What are the Rome 4 criteria and management options for functional abdominal pain disorders in children?

Rome IV Criteria for Functional Abdominal Pain Disorders in Children

The Rome IV criteria define four distinct functional abdominal pain disorders in children: functional dyspepsia, irritable bowel syndrome, abdominal migraine, and functional abdominal pain not otherwise specified, which are diagnosed based on specific symptom patterns and the exclusion of organic disease.

Diagnostic Criteria Overview

General Requirements for All Functional Abdominal Pain Disorders

• Symptoms must be present at least 4 days per month for at least 2 months before diagnosis 1
• No evidence of inflammatory, anatomic, metabolic, or neoplastic process that explains the symptoms 1, 2
• Symptoms cannot be fully explained by another medical condition 2

Specific Criteria for Each Subtype

Functional Dyspepsia

• Must include one or more of the following bothersome symptoms at least 4 days per month 2, 3:
  • Postprandial fullness
  • Early satiation
  • Epigastric pain or burning not associated with defecation
• After appropriate evaluation, the symptoms cannot be fully explained by another medical condition 3
• Two subtypes exist 4:
  • Postprandial Distress Syndrome: Bothersome postprandial fullness or early satiation severe enough to interfere with normal activities
  • Epigastric Pain Syndrome: Bothersome epigastric pain or burning not associated with defecation

Irritable Bowel Syndrome

• Must include all of the following 2, 5:
  • Abdominal pain at least 4 days per month associated with one or more of:
    • Related to defecation
    • Change in frequency of stool
    • Change in form (appearance) of stool
• After appropriate evaluation, symptoms cannot be fully explained by another medical condition 5

Abdominal Migraine

• Must include all of the following 2, 5:
  • Paroxysmal episodes of intense, acute periumbilical, midline, or diffuse abdominal pain lasting ≥1 hour
  • Episodes separated by weeks to months
  • Pain interferes with normal activities
  • Stereotypical pattern and symptoms in the individual patient
  • Pain associated with two or more of: anorexia, nausea, vomiting, headache, photophobia, or pallor
• After appropriate evaluation, symptoms cannot be fully explained by another medical condition 5

Functional Abdominal Pain - Not Otherwise Specified

• Must include all of the following 2, 5:
  • Episodic or continuous abdominal pain that does not occur solely during physiologic events
  • Insufficient criteria for irritable bowel syndrome, functional dyspepsia, or abdominal migraine
• After appropriate evaluation, symptoms cannot be fully explained by another medical condition 5

Diagnostic Approach

• Diagnosis is primarily clinical, based on symptom patterns and exclusion of organic disease 1, 6
• The Rome IV questionnaire (QPGS-IV) has shown 75% sensitivity and 90% specificity for diagnosing functional abdominal pain disorders in children 6
• Avoid unnecessary invasive diagnostic procedures when symptoms are typical and red flags are absent 1

Red Flags Requiring Further Investigation

• Weight loss or deceleration of growth 3
• Persistent right upper or right lower quadrant pain 3
• Dysphagia or odynophagia 3
• Persistent vomiting 3
• Gastrointestinal blood loss 3
• Family history of inflammatory bowel disease, celiac disease, or peptic ulcer disease 3
• Nocturnal symptoms that awaken the child 3

Management Approaches

• Treatment should focus on a combined approach targeting the gut-brain axis, as functional abdominal pain disorders are disorders of gut-brain interaction 1
• Mind-targeted interventions have shown efficacy 1:
  • Hypnotherapy
  • Cognitive behavioral therapy
• Dietary interventions 1:
  • Probiotics may be beneficial
  • Identify and avoid trigger foods
• Percutaneous electrical nerve field stimulation has shown promise 1
• Pharmacological options are limited in children but may include 3:
  • Low-dose antidepressants for pain modulation
  • Proton pump inhibitors for functional dyspepsia (especially epigastric pain syndrome)
  • Prokinetics for functional dyspepsia with postprandial distress syndrome

Clinical Considerations

• Functional abdominal pain disorders affect 3-16% of children worldwide, varying by country, age, and sex 1
• These disorders significantly impact quality of life and school attendance 1, 3
• There is often overlap between different functional abdominal pain disorders, with many children meeting criteria for more than one disorder 5
• The timing of disruption to the microbiota-gut-brain axis appears important in pathophysiology 1