What are the diagnostic criteria for functional dyspepsia in a pediatric patient?

From the Guidelines

Functional dyspepsia in children should be diagnosed and managed according to the latest Rome IV criteria, which require symptoms to have been present for at least 8 weeks, and treatment should focus on lifestyle modifications and medication management to improve symptoms and quality of life. The diagnosis of functional dyspepsia (FD) in children involves identifying the cardinal symptoms of epigastric pain or burning, postprandial fullness, or early satiation, and excluding organic causes through history, physical examination, and sometimes endoscopy or other tests 1. The British Society of Gastroenterology guidelines on the management of FD provide a practical framework for evidence-based diagnosis and treatment, and recommend a stepped-care approach to management, starting with lifestyle modifications and then adding medication as needed 1.

Key Considerations

• Lifestyle modifications, such as smaller, more frequent meals, avoiding trigger foods, and ensuring adequate sleep and stress management, are essential in managing FD symptoms.
• Medication management, including proton pump inhibitors, H2 blockers, prokinetics, and low-dose tricyclic antidepressants, can be effective in improving symptoms, but should be used judiciously and under close supervision.
• The pathophysiology of FD involves altered gut motility, visceral hypersensitivity, and dysregulation of the gut-brain axis, and treatment should aim to address these underlying mechanisms.
• Regular follow-up is recommended to monitor symptoms and adjust treatment as needed, and to provide reassurance about the benign nature of the condition.

Treatment Options

• Proton pump inhibitors, such as omeprazole (0.7-3.5 mg/kg/day divided twice daily) or lansoprazole (0.5-2 mg/kg/day), can be tried for 4-8 weeks to improve symptoms.
• H2 blockers, such as ranitidine (4-10 mg/kg/day divided twice daily), are alternatives to proton pump inhibitors.
• Prokinetics, such as domperidone (0.2-0.4 mg/kg/dose three times daily), may help with motility issues, though availability varies by country.
• Low-dose tricyclic antidepressants, such as amitriptyline (0.2-0.5 mg/kg/day at bedtime), can be considered for pain modulation in refractory cases.

From the Research

Definition and Prevalence of Functional Dyspepsia in Children

• Functional dyspepsia (FD) is a widely prevalent problem in pediatrics, reportedly occurring in 3% to 27% of children 2.
• FD is defined by the Rome III classification as persistent upper abdominal pain or discomfort, not related to bowel movements, and without an organic cause, that is present for at least 2 months prior to diagnosis 2.

Causes and Pathophysiology of Functional Dyspepsia

• Abnormal sensory perception, motor dysfunction, and psychosocial factors have been implicated in the causation of FD 2.
• Hypersensitivity to gastric distension, delayed gastric emptying, antral hypomotility, and gastric dysrhythmia are some abnormalities that have been noted in FD 2.
• Physiologic, genetic, environmental, and psychological factors, as well as various functional abnormalities, such as increased sensitivity to acid, increased sensitivity to duodenal lipids and low-grade inflammation, can cause FD 3.

Diagnosis of Functional Dyspepsia

• Diagnosis of FD is based on a thorough history and examination, and an appropriate selection of tests based on clinical judgment, the presence of alarm signs, and response to treatment 2.
• The Rome IV criteria should be used to diagnose functional dyspepsia 3.
• Assessment of gastric emptying with scintigraphy or breath testing may be useful in identifying delayed gastric emptying in patients with dyspeptic symptoms 4.

Treatment of Functional Dyspepsia

• A biopsychosocial approach to treatment involving medications, psychological and social supports, and complementary therapies is advocated 2.
• Proton pump inhibitors (PPIs) and prokinetics are commonly used first-line medications 2, 4.
• PPIs may be more efficacious and cost-effective than H2 blockers according to adult data 2.
• Lifestyle modifications, such as frequent small meals, low-fat diet, and avoidance of certain aggravating foods, may improve symptoms 4.
• Antacids and over-the-counter histamine type 2 receptor antagonists may be helpful as an "on-demand" therapy for intermittent symptoms 4.

Efficacy of Proton Pump Inhibitors in Functional Dyspepsia

• PPIs are slightly more effective than placebo at relieving overall dyspepsia symptoms in people with FD 5.
• PPIs may be slightly more effective than H2RAs and prokinetics at relieving overall dyspepsia symptoms in people with FD 5.
• PPIs plus prokinetics were possibly slightly more effective than PPIs alone at relieving overall dyspepsia symptoms 5.