Diagnosis: Rome III Pediatric Criteria

Functional dyspepsia
- Upper abdominal pain or discomfort several times weekly or more
- Duration 2 months or longer
- Not exclusively relieved with defecation
- Not associated with change in stool form or frequency
Irritable bowel syndrome
- Upper or lower abdominal pain once weekly or more
- Duration 2 months or longer
- At least sometimes relief with defecation and change in stool form/frequency
Abdominal migraine
- Severe abdominal pain lasting 1 hour or longer and restricting activities
- At least twice in last year, symptom-free period
- Specific associated symptoms (anorexia, nausea/vomiting, pallor, headache, photophobia)
Functional abdominal pain
- Upper or lower abdominal pain once weekly or more
- Duration 2 months or longer
- Does not fit other diagnosis
FAP syndrome
- Upper or lower abdominal pain several times weekly or more
- Duration 2 months or longer
- Misses activities at least once in a while
  OR at least 2 somatic symptoms weekly:
  - Headache
  - Insomnia
  - Pain in arms/legs/back
  - Faint or dizzy

Note:

Functional constipation
Nonretentive fecal incontinence
Aerophagia
Cyclic vomiting syndrome
Adolescent rumination syndrome

These are not abdominal pain syndromes

Functional dyspepsia

Symptoms

Early satiety (most common symptom)
- Often underreported unless specifically elicited.
- May be misinterpreted as bloating, postprandial discomfort, or fullness—even when meal size is not reduced.
Postprandial fullness
Epigastric pain or epigastric burning

Alarm Features (“Red Flags”) – Require Urgent Endoscopy

New onset of symptoms in older age
Unintentional weight loss
Persistent vomiting
Gastrointestinal bleeding
Iron deficiency anaemia
Progressive dysphagia or odynophagia
Family history of upper gastrointestinal malignancy

Rome IV Diagnostic Criteria

Diagnosis requires:

Presence of symptoms for ≥3 days/week over the last 3 months
Symptom onset ≥6 months before diagnosis
No evidence of organic/systemic/metabolic disease on routine investigations (including gastroscopy)

1. Postprandial Distress Syndrome (PDS)

Bothersome postprandial fullness or early satiety
Symptoms severe enough to interfere with normal activities or completing a regular meal

2. Epigastric Pain Syndrome (EPS)

Bothersome epigastric pain or burning
Occurs ≥1 day/week

Diagnosis Approach

Clinical diagnosis of exclusion
Must exclude structural gastrointestinal pathology (via history, examination, and investigation as appropriate)

Differential Diagnoses

Condition	Features
GORD	May overlap; if not responsive to PPI, evaluate for functional dyspepsia. May coexist.
Irritable Bowel Syndrome (IBS)	Overlapping symptoms (e.g. bloating, postprandial discomfort), but FD does not involve altered bowel habits. Both may follow gastroenteritis.
Gastroparesis	Rare but should be considered if persistent vomiting or weight loss. Confirm with gastric emptying study.

Pathophysiology (Proposed Mechanisms)

Multifactorial and incompletely understood
Involves:
- Upper GI inflammation
- Impaired gastric accommodation or motility
- Delayed gastric emptying (~20% of cases)
- Post-infectious or post-allergic dysregulation
- Altered gut-brain axis and microbiome composition

Management Overview

Treatment Modality	PDS Postprandial distress syndrome	EPS Epigastric pain syndrome	Notes
Reassurance & Education	✔️	✔️	Stress reduction is key. Screen for depression/anxiety.
Dietary Modification	✔️	✔️	Regular, low-fat meals; consider low-FODMAP diet if symptoms persist
Acid Suppression (PPI or H2RA)	✔️	✔️✔️	Especially useful in EPS; trial may help symptom control
Prokinetics (e.g. domperidone, metoclopramide)	✔️✔️	✔️	Use cautiously due to QT prolongation risk
Fundic relaxants (e.g. buspirone)	✔️	❌	Limited evidence; may help PDS
Tricyclic antidepressants (e.g. amitriptyline 10–25 mg nocte)	✔️	✔️✔️	May improve visceral hypersensitivity. Titrate slowly.
Rifaximin	✔️	✔️	May benefit selected patients; limited but emerging evidence
Psychological therapy (CBT, gut-directed hypnotherapy)	✔️✔️	✔️	Consider if coexisting psychological distress; effective in some patients

Legend:
✔️ = limited evidence of efficacy
✔️✔️ = efficacious
❌ = not useful

Abdominal migraine

Definition (Pragmatic Clinical Criteria)

Adapted from Symon & Russell, Rome IV, ICHD-3beta.

Episodic, moderate to severe, central abdominal pain lasting ≥1 hour
Normal activity is impaired during episodes
Occurs with ≥1 of the following:
- Pallor
- Anorexia
- Nausea or vomiting
- Photophobia
- Headache
- Association with other episodic syndromes (e.g. cyclic vomiting syndrome, migraine limb pain)
Asymptomatic and well between episodes
Normal physical exam and development

Clinical History

Typically onset in childhood, commonly <7 years
Natural history: Most outgrow it by adolescence; some develop classic migraine later
Often a family or personal history of migraine or related episodic syndromes
High prevalence of undiagnosed similar episodes in parents

Triggers

Processed meats (nitrates), chocolate, and other food additives
Sleep deprivation or fatigue
Stress or emotional upset
Motion sickness (e.g. car or travel-related)
Skipping meals
Disruptions in routine

Relieving Factors

Rest (88%)
Sleep (64%)
Analgesics (38%)
Migraine-directed medications (NSAIDs, antiemetics, triptans)

Clinical Features

Paroxysmal, moderate to severe periumbilical or diffuse pain lasting ≥1 hour
Episodes recur at least twice in 6 months, separated by symptom-free intervals
Pain is often incapacitating
Normal weight, growth, neurological exam, and development
Associated symptoms (≥2 required):
- Anorexia
- Nausea or vomiting (may progress to cyclic vomiting syndrome)
- Headache
- Photophobia
- Pallor
Follows typical migraine phases, with acute episodes lasting 2–72 hours

Phases of a Migraine Attack

Phase	Description	Common Symptoms
First Phase	Premonitory – Early warning symptoms that a migraine attack is starting	– Mood changes – Food cravings – Yawning – Brain fog – Disturbed sleep – Frequent urination – Nausea – Aches and stiffness – Speech difficulties – Language problems
Second Phase	Aura – Occurs in about 1/3 of people with migraine	– Visual disturbances – Numbness – Weakness – Confusion – Difficulty speaking – Dizziness – Vomiting – Abdominal pain
Third Phase	Acute – The headache phase (not everyone experiences headache)	– Headache – Nausea/vomiting – Giddiness – Insomnia – Nasal congestion – Mood changes – Sensitivity to light, sound, smell – Neck pain
Fourth Phase	Resolution – Symptoms start to fade or stop suddenly	– Sudden end to acute symptoms – Urgent need to sleep – Fatigue – Euphoria or suddenly feeling good
Fifth Phase	Postdrome – Also known as the “migraine hangover”	– Fatigue – Depressed mood – Euphoric mood – Brain fog – Lack of comprehension
Sixth Phase	Interictal – The phase between migraine attacks	– No attack symptoms

Diagnosis

Clinical diagnosis – no investigations required once red flags are excluded
Consider other causes if:
- Persistent weight loss
- GI bleeding
- Abnormal physical findings
- Severe persistent vomiting outside typical pattern
Excellent long-term prognosis – no lasting neurological or developmental effects

Management Approach

1. General Measures

Reassurance: Validate and explain the diagnosis to the child and family
Avoid labelling as psychogenic
Identify and avoid known triggers
Maintain regular meals, hydration, sleep, and stress reduction

2. Acute Treatment

Environmental control:
- Rest in a dark, quiet room
Analgesics:
- Paracetamol 15 mg/kg orally
- Ibuprofen 10 mg/kg orally
Triptans:
- Sumatriptan 10 mg intranasally (children ≥12 years)

3. Preventive Therapy (for frequent or severe attacks)

Medication	Class	Dose
Pizotifen	Serotonin antagonist	0.25 mg BD as syrup
Propranolol	Beta-blocker	10–20 mg BD–TDS
Cyproheptadine	Antihistamine	0.25–0.5 mg/kg/day as syrup
Flunarizine	Calcium channel blocker	5–7.5 mg daily
Sodium valproate	Antiepileptic	500 mg TDS IV (hospital use only)
Dihydroergotamine	Ergot alkaloid	0.5 mg IV, repeated to total 7–9 mg (hospital use)

Key Considerations

Avoid misdiagnosis as functional or psychogenic pain
Educating families reduces anxiety and medical over-investigation
Prophylaxis is reserved for frequent, disabling episodes or if significantly impairing quality of life

Functional Abdominal Pain (FAP) in Children

💡 Definition (Rome IV-Informed)

Functional abdominal pain is a diagnosis of exclusion and should be considered when:

Abdominal pain occurs ≥4 times per month for ≥2 months
Does not meet criteria for IBS, functional dyspepsia, or abdominal migraine
Pain cannot be fully explained by another medical condition after appropriate evaluation
Pain does not solely occur in relation to physiological events (e.g. menses, eating)
Can coexist with chronic conditions such as IBD
Pain is often exacerbated by psychological stressors (e.g. school stress, family conflict)

Alarm Symptoms – Prompt Further Evaluation

History Features

Family history: IBD, coeliac disease, peptic ulcer disease
Persistent RUQ or RLQ pain
Dysphagia or odynophagia
Persistent vomiting
Gastrointestinal bleeding (overt or occult)
Nocturnal diarrhoea
Joint pain or arthritis
Perianal disease
Involuntary weight loss or poor growth
Delayed puberty
Unexplained fever

Physical Exam Findings

Abdominal mass
Hepatosplenomegaly
Spinal or joint tenderness, swelling, redness, warmth
Jaundice
Perianal abnormalities (tags, fissures, fistulas)
Clubbing
Erythema nodosum or pyoderma gangrenosum

Psychosocial Context and Functional Pain Pattern

Family history often includes IBS, GORD, constipation
Child is well and active between episodes
Common comorbid symptoms:
- Anxiety
- Depression
- Separation anxiety
- Social or specific phobias
- Generalised anxiety

Pain Description

Often described as constant, diffuse, or hard to localise
Not clearly related to eating or defecation
May begin in early childhood and evolve over time
Perceived in emotional terms rather than somatic localisation

Pain-Related Behaviour Patterns

Pain may diminish during distraction and worsen during stress or focused discussion
Describes pain as extreme (e.g., always “10/10”)
Denial of emotional or psychological contributions, attributing distress to the pain itself
Requests for extensive testing or validation through diagnosis or procedures
Focus on complete symptom relief rather than coping or adaptation
Frequent healthcare visits; low engagement in self-management
Potential requests for narcotics, despite limited organic findings

Biopsychosocial Management Approach

Biological Treatment

Educate that analgesics often have limited effect (visceral hypersensitivity mechanism)
Treat constipation if suspected
Consider PPI trial if features of dyspepsia, but set realistic expectations
Antispasmodics: limited evidence
Avoid unnecessary medications; support symptom reattribution

Psychological Interventions

Distraction techniques effective in reducing symptom severity
Address coexisting anxiety, emotional distress, or school avoidance
Support child and parent understanding of functional nature of pain → strongest predictor of improvement

Social Goals

Reintegration into normal activities: e.g., school return (even part-time), walking daily
Use developmentally appropriate metaphors (e.g., “pain creature in the tummy” breathing techniques)
Encourage graded exposure to feared or avoided situations

Follow-Up

Most children can be managed in general practice
Arrange follow-up to reinforce education, monitor function, and adjust support as needed
Refer to paediatric gastroenterology or psychology only if:
- Alarm features present
- Severe functional impairment persists despite management

🗣️ Example Explanation to Families

This type of tummy pain is common in children and teens.
We may not be able to stop the pain completely, but we can help you feel better and get back to doing what you enjoy.
Sometimes after an illness or stress, the gut becomes more sensitive.
The body starts to feel pain from things that don’t usually hurt (like gas or stretching).
It’s like the body’s pain alarm is set too high.
Even if the pain feels strong, it doesn’t mean something serious is wrong.
Stress, worry, or big feelings can cause tummy pain too.
It’s similar to how some people get headaches or feel sick when they’re upset.

“This type of pain is very common in children and adolescents. While we may not be able to stop the pain completely, we can work together to help you feel better and keep doing the things you enjoy.”

“After an illness or stress, the body’s way of processing pain can change. The gut becomes more sensitive to normal sensations like stretching or gas, and the brain responds by sending stronger pain signals. We call this up-regulation of the pain pathway—it’s like your pain thermostat has been turned up too high.”

“The severity of pain does not necessarily mean something serious is wrong. In fact, stress and emotional changes can also trigger this kind of gut pain—just like some people get headaches or feel sick when they’re worried.”