What is the recommended evaluation and management for a child or adolescent with functional (non‑ulcer) dyspepsia?

Evaluation and Management of Pediatric Functional (Non-Ulcer) Dyspepsia

Critical Age-Specific Limitation

The available evidence base for functional dyspepsia management is derived almost entirely from adult populations, with no high-quality pediatric-specific guidelines identified. The British Society of Gastroenterology 2022 guidelines 1 and other major society recommendations 2, 3, 4 do not provide pediatric-specific thresholds, dosing, or management algorithms. Therefore, the following approach extrapolates adult evidence to the pediatric population with appropriate clinical judgment regarding alarm features, endoscopy thresholds, and medication dosing.

Diagnostic Approach

Clinical Diagnosis

• Diagnose functional dyspepsia in children and adolescents presenting with bothersome epigastric pain or burning, early satiation, and/or postprandial fullness lasting more than 8 weeks, in the absence of alarm symptoms. 1

• Alarm features requiring urgent investigation in pediatric patients include:

  • Unintended weight loss or growth failure 1, 5
  • Progressive dysphagia 5
  • Recurrent vomiting 1
  • Overt gastrointestinal bleeding or anemia 5
  • Family history of gastric or gastro-esophageal cancer 1, 5

Initial Laboratory Testing

• Obtain a complete blood count to exclude anemia in all pediatric patients with dyspepsia 1

• Perform coeliac serology (tissue transglutaminase antibodies) in all children with functional dyspepsia who have overlapping irritable bowel syndrome-type symptoms (bloating, altered bowel habits). 1

Role of Endoscopy

• In the absence of alarm features, endoscopy is not required to establish the diagnosis of functional dyspepsia in children and adolescents. 1, 2

• The adult age threshold of 55 years for mandatory endoscopy 1, 5 does not apply to pediatric populations; however, consider endoscopy in adolescents with treatment-resistant symptoms after failed empirical therapy 1, 2

• Endoscopy performed solely for reassurance does not improve outcomes in anxious patients or their families. 2

• Gastric emptying studies and 24-hour pH monitoring should not be performed routinely in children with typical functional dyspepsia symptoms 1, 2

Establishing Therapeutic Alliance

Before initiating pharmacologic therapy, establish an empathic doctor-patient-family relationship and provide education about functional dyspepsia as a disorder of gut-brain interaction. 1

• Explain that functional dyspepsia is influenced by diet, stress, cognitive and emotional responses, and sometimes follows gastrointestinal infections 1

• Clarify the natural history and common symptom triggers to reduce healthcare utilization and improve quality of life 1

• This communication strategy has strong evidence for reducing anxiety and improving outcomes in adult populations 1, 2

First-Line Treatment

Helicobacter pylori Testing and Eradication

• Test all pediatric patients with functional dyspepsia for H. pylori using non-invasive methods: 13C-urea breath test (preferred) or stool antigen assay. 1, 2

• If H. pylori is positive, provide eradication therapy immediately using standard triple therapy (proton pump inhibitor + clarithromycin + amoxicillin). 1, 2

• Eradication leads to symptom improvement in approximately 1 in 15 patients and may reduce future gastric cancer risk 1, 2

• Adverse events are more common with eradication therapy than placebo, but the regimen is generally well-tolerated 1

Acid Suppression Therapy

• For children who are H. pylori-negative or whose symptoms persist after successful eradication, initiate a 4–8 week trial of standard-dose proton pump inhibitor (PPI) once daily. 1, 2

• PPIs are superior to H₂-receptor antagonists, antacids, and placebo for functional dyspepsia 2

• Use the lowest dose that controls symptoms; there is no dose-response relationship for efficacy 1

• PPIs benefit both epigastric pain syndrome and postprandial distress syndrome subtypes 2

Lifestyle Modifications

• Advise all pediatric patients with functional dyspepsia to engage in regular aerobic exercise. 1

• Evidence is insufficient to recommend specific dietary therapies, including low-FODMAP diets, in functional dyspepsia 1, 4

• Counsel families to limit foods that consistently trigger symptoms on an individual basis 4

Second-Line Treatment for Refractory Symptoms

For Pain-Predominant Symptoms

• Tricyclic antidepressants (TCAs) are the most evidence-based second-line treatment for refractory functional dyspepsia. 1, 2, 3

• Begin amitriptyline at 10 mg once nightly and titrate slowly to 30–50 mg once nightly as tolerated. 1, 2

• Careful explanation of the rationale for TCA use as a gut-brain neuromodulator (not an antidepressant) is essential to ensure adherence 1

• Counsel patients and families about the side effect profile, including sedation, dry mouth, and constipation 1

• Continue TCA therapy for 6–12 months in patients who respond 3

For Dysmotility-Predominant Symptoms

• Consider adding a prokinetic agent when symptoms of postprandial fullness, early satiety, bloating, or upper abdominal discomfort persist after PPI trial. 2

• Itopride is the preferred prokinetic agent, with an excellent safety profile (adverse events ≈1.5–3%) and no cardiac toxicity or QT prolongation. 2

• Alternative prokinetics (mosapride, acotiamide, tegaserod) have variable availability and efficacy; many are unavailable outside Asia and the USA 1, 2

• The overall quality of evidence for prokinetics is low to moderate, with modest symptomatic benefit 1, 2

Combined Therapy for Mixed Symptoms

• Levosulpiride 25 mg three times daily may be combined with amitriptyline for patients with both pain and dysmotility symptoms. 2

• Counsel about additive drowsiness and possible hyperprolactinemia 2

Referral to Pediatric Gastroenterology

Refer to pediatric gastroenterology when:

• Diagnostic uncertainty exists 1, 2
• Symptoms are severe or refractory to first-line treatments 1, 2
• The patient or family requests specialist opinion 1
• Alarm features develop during follow-up 1, 5

Ideally, manage referred patients in a specialist clinic with access to dietetic support, efficacious medications, and gut-brain behavioral therapies 1

Common Pitfalls to Avoid

• Do not perform repetitive or extensive diagnostic testing in the absence of alarm features; this yields low diagnostic benefit and is not cost-effective. 2

• Do not continue full-dose PPI therapy indefinitely; attempt treatment withdrawal after symptom control to assess ongoing need, and use the lowest effective dose or on-demand therapy. 2

• Do not dismiss the importance of psychological comorbidity; patients with functional dyspepsia often have anxiety and depression that require concurrent management. 6, 7

• Do not use metoclopramide as a first-line prokinetic in pediatric patients due to risk of extrapyramidal side effects; itopride has a superior safety profile. 2