What are the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) guidelines for diagnosing and managing functional gastrointestinal disorders in pediatric patients?

NASPGHAN Guidelines on Pediatric Functional Gastrointestinal Disorders

Overview and Scope

NASPGHAN has developed comprehensive evidence-based guidelines for pediatric functional gastrointestinal disorders in collaboration with ESPGHAN, covering functional constipation, irritable bowel syndrome (IBS), and functional abdominal pain disorders in children. 1, 2, 3

The most recent collaborative guidelines address:

• Functional constipation (2014, with 2024 update protocol published) 1, 2
• IBS and functional abdominal pain-not otherwise specified (FAP-NOS) in children aged 4-18 years (2025) 3
• Functional disorders in infancy including infantile colic 4

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Functional Constipation Guidelines

Diagnostic Approach

The Rome IV criteria should be used for diagnosis, requiring at least 2 of the following symptoms for ≥1 month in children ≥4 years (or ≥2 months in infants): two or fewer defecations per week, at least one episode of fecal incontinence per week, history of retentive posturing or excessive volitional stool retention, history of painful or hard bowel movements, presence of large fecal mass in the rectum, or history of large diameter stools. 2

Key diagnostic elements include:

• History and physical examination focusing on stool frequency, consistency (Bristol Stool Scale), pain with defecation, withholding behaviors, soiling episodes, and dietary intake 2
• Abdominal examination for palpable fecal mass and digital rectal examination to assess for fecal impaction, anal fissures, and rectal tone 2
• Red flags requiring further investigation: onset before 1 month of age, passage of meconium >48 hours, ribbon stools, blood in stools in absence of anal fissures, failure to thrive, fever, bilious vomiting, severe abdominal distention, abnormal thyroid gland, abnormal position of anus, absent cremasteric reflex, decreased lower extremity strength/tone/reflexes, tuft of hair or dimple on spine, gluteal cleft deviation 2

Treatment Algorithm

First-line treatment consists of disimpaction followed by maintenance therapy with polyethylene glycol (PEG), which has the strongest evidence base. 2

Disimpaction Phase

• Oral PEG 1-1.5 g/kg/day for 3-6 consecutive days is the preferred method 2
• Rectal therapies (enemas, suppositories) may be used if oral route fails or is refused, but are not first-line due to invasiveness and potential psychological impact 2

Maintenance Phase

• PEG at 0.4-0.8 g/kg/day is recommended as first-line maintenance therapy based on superior efficacy and tolerability compared to lactulose and milk of magnesia 2
• Lactulose (1-3 mL/kg/day divided twice daily) is an acceptable alternative if PEG is unavailable or not tolerated 2
• Magnesium hydroxide (1-3 mL/kg/day) can be used as second-line therapy 2
• Stimulant laxatives (senna, bisacodyl) should be reserved for rescue therapy or short-term use when osmotic laxatives fail 2

Duration and Follow-up

• Maintenance therapy should continue for at least 2 months, with gradual weaning only after regular bowel pattern established for several weeks 2
• Follow-up visits should occur at 2-4 week intervals initially, then every 3-6 months during maintenance 2

Interventions NOT Recommended

• Routine use of abdominal radiographs for diagnosis or monitoring is not recommended 2
• Routine anorectal manometry, colonic transit studies, or rectal biopsy are not indicated in uncomplicated functional constipation 2
• Prebiotics, probiotics, and fiber supplementation have insufficient evidence to recommend routinely 2
• Behavioral interventions alone without laxative therapy are insufficient for treatment 2

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IBS and Functional Abdominal Pain Guidelines

Diagnostic Criteria

Diagnosis is based on Rome IV criteria: abdominal pain at least 4 days per month for at least 2 months, associated with one or more of the following: related to defecation, change in stool frequency, or change in stool form/appearance. 3

• Extensive laboratory testing and imaging are not required in children meeting Rome IV criteria without alarm features 3
• Alarm features requiring investigation: involuntary weight loss, deceleration of linear growth, gastrointestinal blood loss, significant vomiting, chronic severe diarrhea, persistent right upper or right lower quadrant pain, unexplained fever, family history of inflammatory bowel disease 3

Treatment Recommendations

The 2025 ESPGHAN/NASPGHAN guidelines provide 25 GRADEd recommendations based on systematic review of 86 randomized controlled trials. 3

Dietary Interventions

• Low FODMAP diet can be considered for children ≥8 years with IBS, implemented with dietitian supervision for 4-6 weeks, followed by systematic reintroduction 3
• Lactose restriction should only be pursued if lactose malabsorption is documented 3
• Gluten-free diet is not recommended unless celiac disease is diagnosed 3

Pharmacological Interventions

• Peppermint oil (enteric-coated capsules) can be used for children ≥8 years with IBS, dosed at 187-374 mg three times daily 3
• Antispasmodics (hyoscine butylbromide, mebeverine) may provide short-term symptom relief but have limited evidence 3
• Tricyclic antidepressants (amitriptyline 10-30 mg at bedtime) can be considered for refractory cases in children ≥12 years 3
• Proton pump inhibitors are not recommended for functional abdominal pain without documented acid-related disease 3

Psychological Interventions

• Cognitive behavioral therapy (CBT) and gut-directed hypnotherapy are recommended as effective treatments with strong evidence base 3
• These interventions should be delivered by trained professionals over 6-12 sessions 3

Probiotics

• Lactobacillus rhamnosus GG and VSL#3 have modest evidence for symptom improvement in IBS 3
• Routine probiotic use cannot be recommended due to heterogeneity in strains, doses, and outcomes 3

Critical Management Pitfalls

• Avoid repeated invasive testing in children with typical functional symptoms and no alarm features 3
• Do not dismiss symptoms as "just functional"—these disorders significantly impair quality of life and require active management 3, 4
• Avoid multiple simultaneous dietary restrictions without evidence, as this can lead to nutritional deficiencies and food anxiety 3

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Functional Disorders in Infancy

Infantile Colic

Primary management focuses on parental reassurance and education, as colic is self-limited and resolves by 4-5 months in most infants. 4

• Nutritional interventions are first-line when reassurance is insufficient: for formula-fed infants, trial of extensively hydrolyzed or amino acid-based formula for 2 weeks; for breastfed infants, maternal elimination of cow's milk protein for 2-4 weeks 4
• Lactobacillus reuteri DSM 17938 (10^8 CFU daily) may reduce crying time in exclusively breastfed infants with colic 4
• Simethicone, gripe water, and herbal preparations are not recommended due to lack of efficacy 4
• Avoid inappropriate medication use, particularly proton pump inhibitors, which are commonly overprescribed and ineffective for colic 4

Infant Dyschezia and Functional Constipation

Infant dyschezia (straining without hard stools) requires only parental education and reassurance—no intervention is needed. 4

• True functional constipation in infants <6 months requires different management than older children, with glycerin suppositories as needed for hard stools 2
• Oral laxatives should be used cautiously in infants <6 months, with PEG preferred if needed 2

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Quality of Life and Family Impact

Functional GI disorders occur in nearly 50% of infants and significantly impair quality of life for both the child and family, imposing substantial financial burden on healthcare systems. 4

• Healthcare providers must recognize the psychological and social impact of these disorders and provide empathetic, evidence-based care 4
• Parental anxiety and stress are major contributors to healthcare utilization and should be addressed directly 4
• Inappropriate interventions (excessive testing, ineffective medications) can worsen family anxiety and should be avoided 4

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Future Directions

The 2024 NASPGHAN/ESPGHAN protocol for updated constipation guidelines emphasizes the need for large, well-designed pediatric trials using GRADE methodology and network meta-analysis to address current evidence gaps. 1

• Major research needs include optimal duration of therapy, weaning strategies, role of behavioral interventions, and comparative effectiveness of different laxative regimens 1
• For IBS and FAP, future studies should focus on standardized outcome measures, longer follow-up periods, and identification of treatment responders 3