What are the diagnostic criteria and management options for non-ulcer dyspepsia in pediatric patients?

Non-Ulcer Dyspepsia in Pediatrics: Diagnostic Criteria

Non-ulcer dyspepsia (functional dyspepsia) in children is diagnosed when chronic or recurrent epigastric pain or discomfort persists for at least 8 weeks without structural or biochemical abnormalities on appropriate investigation, primarily upper endoscopy with biopsy. 1

Diagnostic Criteria

Core Symptom Requirements

The diagnosis requires one or more of the following cardinal symptoms present for a minimum of 8 weeks (using clinical criteria rather than the more restrictive 6-month Rome IV research criteria): 1

• Bothersome epigastric pain - pain severe enough to interfere with daily activities 1
• Bothersome epigastric burning 1
• Bothersome postprandial fullness - excessive fullness after normal-sized meals 1
• Bothersome early satiation - inability to finish a normal meal due to premature fullness 1

Associated Symptoms (May Coexist)

• Belching, nausea, or upper abdominal bloating can be present 1
• Symptoms in children often include vomiting, poor weight gain, anorexia, and feeding-related complaints 2

Critical Exclusions

You must exclude GERD as a primary diagnosis - heartburn alone is NOT dyspepsia, though it can coexist. If heartburn is the predominant symptom, the patient has GERD, not functional dyspepsia. 1

Warning signs that mandate immediate investigation and suggest alternative diagnoses: 1

• Bilious vomiting
• GI bleeding (hematemesis or hematochezia)
• Consistently forceful vomiting
• Fever, lethargy
• Hepatosplenomegaly
• Bulging fontanelle, macro/microcephaly, seizures
• Abdominal tenderness or distension
• Poor weight gain or weight loss
• Documented genetic/metabolic syndrome

Mandatory Diagnostic Evaluation

Upper endoscopy with esophageal and gastric biopsies is required to establish the diagnosis - this is not optional, as functional dyspepsia is by definition a diagnosis of exclusion. 1, 3

What Endoscopy Must Rule Out:

• Peptic ulcer disease 1
• Reflux esophagitis 1
• Eosinophilic esophagitis - cannot be diagnosed without tissue sampling and requires different management 3, 4
• Helicobacter pylori gastritis 1
• Crohn's disease 2
• Infectious esophagitis 3

Approximately 25% of infants under 1 year have histologic esophageal inflammation invisible to the naked eye, making biopsy essential even when mucosa appears normal. 3, 4

Additional Testing Considerations

Esophageal manometry should be performed if: 3

• Surgical intervention is being considered
• Major motor disorders need exclusion
• Peristaltic function assessment is needed

24-hour pH monitoring or pH-impedance testing can quantify reflux episodes and establish temporal relationships between symptoms and reflux, but should typically follow endoscopy. 3, 5

Pediatric-Specific Diagnostic Challenges

Age-Related Presentation Differences

In infants (<1 year): 1

• Symptoms are nonspecific and unreliable for diagnosis
• Regurgitation, irritability, feeding refusal, and back arching are common
• Symptoms do not always resolve with acid suppression
• Peak incidence at 4 months (50%), declining to 5-10% by 12 months

In older children and adolescents: 1

• Symptom reliability increases with age
• Adolescents may present with adult-like heartburn patterns
• History and physical examination become more reliable

High-Risk Populations Requiring Lower Threshold for Investigation

Children with these conditions have higher prevalence of severe dyspepsia and warrant earlier endoscopic evaluation: 1

• Neurologic impairment or cerebral palsy
• Obesity
• History of repaired esophageal atresia
• Hiatal hernia
• Achalasia
• Chronic respiratory disorders (bronchopulmonary dysplasia, cystic fibrosis, history of lung transplantation)

Common Diagnostic Pitfalls to Avoid

Do not use empiric PPI therapy as a diagnostic test - lack of response does not rule out GERD, and response does not confirm it. 5

Do not rely on barium studies alone - they are too brief to rule out pathologic reflux, have high false-positive rates from physiologic reflux, and cannot assess mucosal injury or exclude conditions like eosinophilic esophagitis. 5, 4

Do not diagnose functional dyspepsia without endoscopy - 80% of patients with dyspeptic symptoms will have functional dyspepsia after investigation, but you cannot make this diagnosis presumptively. 1

Vomiting is atypical - if prominent vomiting is present, strongly consider alternative diagnoses including gastroparesis, cyclic vomiting syndrome, or rumination. 1

Helicobacter pylori Testing Strategy

Test for H. pylori in all children undergoing evaluation for dyspepsia - eradication cures underlying peptic ulcer disease and prevents future gastroduodenal disease, though many with functional dyspepsia will not gain symptomatic benefit. 1

The test-and-treat strategy is appropriate for uninvestigated dyspepsia in adults but in pediatrics, endoscopy remains the gold standard due to the need to exclude other conditions that are more common in children. 2

Subtype Classification (After Diagnosis Established)

Once functional dyspepsia is confirmed by negative endoscopy, classify into subtypes to guide empiric therapy: 1, 6

Epigastric Pain Syndrome (EPS):

• Epigastric pain or burning at least once weekly
• Often present regardless of meals

Postprandial Distress Syndrome (PDS):

• Early satiation and postprandial fullness at least 3 times weekly
• Mainly triggered by meals

Note: Significant overlap between subtypes is common, particularly in secondary and tertiary care settings. 1