Version May 2024
INTRODUCTION — Functional abdominal pain disorders (FAPDs), also called pain-predominant functional gastrointestinal disorders, are the most common cause of chronic abdominal pain in children and adolescents. FAPDs involve interplay among regulatory factors in the enteric and central nervous systems [1]. FAPDs may be associated with visceral hyperalgesia, reduced threshold for pain, abnormal pain referral after rectal distension, or impaired gastric relaxation response to meals [2-6]. In addition, persistent experiences of pain may have an adverse effect on mental health. (See "Chronic abdominal pain in children and adolescents: Approach to the evaluation", section on 'Pathogenesis'.)
The management of children and adolescents with FAPDs is reviewed here. The evaluation of children and adolescents with chronic abdominal pain, treatment of migraine in children (including abdominal migraine), and FAP in adults are discussed separately.
●(See "Chronic abdominal pain in children and adolescents: Approach to the evaluation".)
●(See "Types of migraine and related syndromes in children", section on 'Abdominal migraine' and "Acute treatment of migraine in children".)
●(See "Functional dyspepsia in adults".)
●(See "Clinical manifestations and diagnosis of irritable bowel syndrome in adults" and "Treatment of irritable bowel syndrome in adults".)
TERMINOLOGY — Functional abdominal pain (FAP) may be diagnosed in children who have all of the following [7]:
●Chronic (≥2 months) abdominal pain
●No alarm findings (table 1)
●Normal physical examination
●Stool sample negative for occult blood
Several pain-predominant functional gastrointestinal disorders of childhood have recognizable patterns of symptoms and include functional dyspepsia, irritable bowel syndrome (IBS), abdominal migraine, and FAP-not otherwise specified (FAP-NOS) (table 2) [7]. (See "Chronic abdominal pain in children and adolescents: Approach to the evaluation", section on 'Diagnosis of functional abdominal pain'.)
Terms that have been used interchangeably with FAP-NOS (often referred to as FAP) include "nonorganic abdominal pain," "psychogenic abdominal pain," and "recurrent abdominal pain." Although the American Academy of Pediatrics and North American Society for Pediatric Gastroenterology, Hepatology and Nutrition clinical report on chronic abdominal pain recommended not using the term "recurrent abdominal pain" as a synonym for functional, psychological, or stress-related abdominal pain, this use persists [8,9].
MANAGEMENT APPROACH — The goal of management of functional abdominal pain disorders (FAPDs) in children and adolescents is return to normal function (ie, rehabilitation) rather than complete elimination of pain [1,8,10-12]. Most cases can be managed in the primary care setting [13]. Referral may be necessary for children and adolescents who do not improve with primary care interventions. (See 'Indications for referral' below.)
The management of FAPDs is challenging because the subtypes are heterogeneous and the pathophysiology is incompletely understood. Individuals with FAPDs may have similar symptoms (eg, abdominal pain, nausea, changes in bowel movements) but different underlying causes. Thus, management is individualized according to child and family behaviors, triggers, and symptoms [14,15].
"Response" to any intervention may reflect the natural history of improvement over time or placebo response as FAPDs resolve with time in the majority of children [16-18].
In a meta-analysis of 17 placebo-controlled randomized trials (pharmacologic or nonpharmacologic) in children age 4 to 18 years with an abdominal pain-related functional gastrointestinal disorder, the pooled placebo response rate for improvement (as defined by the study authors) was 41 percent (95% CI 34-49 percent) and the pooled placebo response rate for no pain was 17 percent (95% CI 8-32 percent) [19]. Although the study did not identify any factors that could be used in clinical practice to optimize the placebo response, the high placebo response rate can be a valuable tool to enhance any treatment strategy. (See 'Prognosis' below.)
The detailed recommendations in the sections below are generally consistent with those outlined in the 2005 American Academy of Pediatrics and North American Society for Pediatric Gastroenterology, Hepatology and Nutrition clinical report on chronic abdominal pain in children [8].
GENERAL MANAGEMENT STRATEGIES — The approach to functional abdominal pain disorders (FAPDs) in children and adolescents typically involves various combinations of: a therapeutic relationship, behavior modification, strategies to improve pain tolerance and coping, avoidance of triggers, and symptomatic management [20,21]. For patients whose pain remains unrelenting and continues to interfere with functioning, referral for noninvasive interventions such as hypnotherapy and auricular neuromodulation may be warranted. Although additional study is necessary, evidence from well-designed, single-center trials supports the efficacy of these interventions.
Therapeutic relationship — A therapeutic clinician-patient/family relationship is an important component of the management of FAPDs. The patient and family must believe that their complaints and concerns are taken seriously [21,22]. Their concerns about specific organic diseases must be addressed (generally by reviewing the manifestations of that disease that are absent in the patient) before management of FAPDs can proceed [12]. The explanation of a biopsychosocial model of functional disease can be helpful (figure 1), as it frames the disease in terms of being a positive diagnosis rather than a diagnosis of exclusion (with the inherent expectation for extensive evaluation). The family's ability to accept such a biopsychosocial model of pain may be an important factor in the child's recovery [23]. (See 'Prognosis' below.)
Some centers have developed a multidisciplinary model of care for patients with FAPDs, usually including a pediatric gastroenterologist, pain specialist, and psychologist. The multidisciplinary team reinforces the biopsychosocial aspects of FAPDs and demonstrates that the patient's and family's concerns are being taken seriously. In observational studies, multidisciplinary care has been associated with reduced pain, increased function, and decreased health care utilization in children with FAPDs [24,25].
The patient and family may be reassured by the clinician's acknowledging that the pain is real and has affected important activities in the patient's life. The patient and family should be assured that the clinician will initiate a treatment plan and continue to regularly follow up with the patient [26]. Periodic follow-up validates the clinician's continued support and interest in the patient and family. (See 'Follow-up' below.)
The therapeutic alliance may be strengthened by focusing on the shared goal of return to normal function for both the patient and family. The pain may be a focal point of the family's life, creating stress for other members. The pediatric care provider can address these effects by prescribing a return to structured activities of daily living, including school attendance (a rehabilitative approach). (See 'Return to school' below.)
Patient education — FAPDs are best treated in the context of a biopsychosocial model of care (figure 1) [8,27-32]. In small observational study, caregiver acceptance of a biopsychosocial model of illness was associated with resolution of pain [23].
Before beginning therapy, the pediatric health care provider should clarify the expectations of the caregivers and patient. Some caregivers may simply want assurance that the pain is not caused by organic illness. Expectations must be realistic (eg, improved function or school attendance rather than complete resolution of pain) [8].
Education should include the following points:
●FAPDs are common, occurring in approximately 10 to 20 percent of children. (See "Chronic abdominal pain in children and adolescents: Approach to the evaluation", section on 'Epidemiology'.)
●The pain of FAPDs is real; it is thought to be caused by a heightened sensitivity to the normal function of the stomach and bowel. (See "Chronic abdominal pain in children and adolescents: Approach to the evaluation", section on 'Pathogenesis'.)
●Like other types of pain, pain in FAPDs can be triggered, exacerbated, or maintained by environmental (eg, gastrointestinal infection, medications) and psychosocial factors, including stress, anxiety, and social reinforcement (eg, attention, staying home from school) [11,21,33,34].
Other examples of physiologic responses to stress or anxiety include headaches, churning of the stomach before a test, and nausea when given bad news.
●The pain of FAPDs is not life-threatening and does not require activity restriction.
●Treatment focuses on rehabilitation: return to normal activity despite discomfort [10,12].
●Management of pain involves avoiding triggers and improving coping skills; the pain may persist, but the child's and family's quality of life can be improved [12].
●Goals for management should be realistic (eg, maintenance of normal activities, increased tolerance of symptoms) [21].
●Chronic pain, regardless of the etiology, can be associated with depression or anxiety (both as a cause and an effect) [35]. (See 'Prognosis' below.)
Return to school — A plan for return to school is crucial. School absenteeism adds to family stress and can interfere with the patient's school performance and social functioning [36]. Homebound schooling is strongly discouraged unless the clinician and school counselor agree that it is necessary (eg, based on academic performance or needs).
In most cases, return to school should immediately follow the diagnosis of FAPD [12]. Caregivers who are concerned about their child's emotional reaction to returning to school may need help in formulating and implementing a plan for graded return to school. They can be encouraged to work with the school to develop a part-time schedule to facilitate the transition. The first day back should be sufficiently short to guarantee success and increase the child and family's confidence in the child's ability to attend school [12].
Return to school may be facilitated by [12,36]:
●Planning ahead for pain episodes at school (eg, being allowed to go to the nurse's office until pain subsides with the caveat that regular use of the nurse's office at school may reinforce symptoms).
●Providing guidelines to help the caregiver decide when the child is too sick to go to school or sick enough to be allowed to come home (eg, fever, vomiting, diarrhea). Regularly sending the child home from school may reinforce symptoms.
●Providing guidelines for activity restriction when the child remains home from school (eg, bedrest without television or other entertainment).
●Identifying and addressing school-related sources of stress (eg, bullying, social isolation, inappropriate classroom placement).
●For children with FAPD and altered bowel patterns, sending a letter requesting that the child be allowed to use the bathroom whenever necessary.
●For families who have an adversarial relationship with the school related to frequent absence, sending a letter to document that the child has undergone an evaluation for gastrointestinal symptoms that have interfered with attendance.
Behavior modification — Return to normal function is facilitated by reinforcement of nonpain (healthy or adaptive) behaviors and avoiding/stopping reinforcement of pain (sick, illness, or maladaptive) behaviors [12,37]. Suggestions for behavior modification techniques may be provided by the primary care provider and/or, as necessary, in a more formal psychotherapy program (eg, cognitive behavior therapy [CBT]).
Examples of reinforcement of well behaviors include [12,34,38]:
●Praising/rewarding the child for attending school or extracurricular activities (eg, using a sticker chart to earn rewards agreed upon in advance for progressively longer periods of consecutive attendance)
●Identifying and supporting the child's interests and skills outside of the sick role (eg, athletic or artistic abilities)
●Caregiver modeling of healthy responses to abdominal pain (eg, deep breathing) (see 'Improved coping' below)
In attempts to be supportive and nurturing, caregivers of children with FAPDs may inadvertently reinforce pain or illness behaviors [21]. Examples of reinforcement of pain behavior that should be avoided include [39]:
●Providing attention to the pain (eg, asking about symptoms); in a randomized trial, spontaneous complaints of pain during symptom provocation (water load) nearly doubled among children whose caregivers were assigned to provide attention (eg, "I can imagine it must feel really uncomfortable") compared with children whose caregivers were not provided with any specific instruction [40].
Scheduling a "symptom report" once per day may be helpful for caregivers and children who have difficulty with immediate and complete discontinuation of asking about or reporting symptoms [12].
●Allowing the pain to disrupt normal function and activity (eg, by allowing the child to stay home from school or leave school, excusing the child from completing their homework) [38].
●Allowing the child who stays home from school to watch television or have access to other forms of entertainment.
Improved coping — Coping is defined as voluntary efforts to regulate emotion, thought, behavior, physiology, and the environment in response to stressful events or circumstances [41]. We suggest incorporation of psychological treatments to improve coping in the management of children and adolescents with FAPDs.
Learning to cope with pain facilitates return to normal function. Randomized and observational studies provide relatively compelling but limited evidence that psychological interventions (eg, relaxation, distraction [including guided imagery/hypnotherapy], CBT, biofeedback) are associated with improved pain tolerance, reduced anxiety, increased nonpain behavior, and improved self-management [42-44].
Although few studies directly compare psychological interventions with "standard pediatric care" (which typically involves education and reassurance with or without dietary interventions or pharmacotherapy), psychological interventions appear to be more effective [45-50]. (See 'Behavior modification' above.)
Relaxation and distraction techniques can be taught by trained primary care clinicians; CBT and biofeedback typically require referral to mental health professionals with specialized training [51].
●Relaxation techniques – Older children and adolescents can be taught brief muscle relaxation techniques such as deep breathing exercises to be performed at least twice a day (table 3) [10]. A family member can act as "coach" if necessary. The goal is to help the child or adolescent relax when in pain.
Progressive muscle relaxation is another relaxation technique that involves systematic tensing and relaxing of each muscle group, focusing attention on the feeling after the muscles are relaxed (table 3) [21].
In observational studies and meta-analyses, relaxation therapy helped to reduce pain and improve function in children with FAPDs [38,52-54].
●Distraction – Distraction shifts attention away from pain [55]. Distraction techniques include conversation, games, television, and guided imagery. In a randomized trial, spontaneous complaints of pain during symptom provocation (water load) were reduced by one-half among children whose caregivers were assigned to provide distraction (eg, "What would you like to do this evening?") attention compared with children whose caregivers were not provided with any specific instruction [40].
●Guided imagery/hypnotherapy – Guided imagery (also called hypnotherapy or self-hypnosis) is a distraction technique through which the child engages in imagery and relaxation, which distracts attention from painful stimuli [46,56]. Guided imagery may incorporate imagined pictures, sounds, or sensations to produce increased receptiveness to gut-specific suggestions and ideas, also known as "gut-directed" hypnotherapy (table 3). Guided imagery/hypnotherapy may be self-directed or performed by a qualified therapist [57].
In a 2017 meta-analysis of four small randomized trials including 146 children with recurrent abdominal pain [45,46,58,59], guided imagery/hypnotherapy was more successful (defined as being pain free or an improvement in pain, according to the individual study) than control medical therapy (absolute rate of improvement 53 versus 14 percent; odds ratio 6.8, 95% CI 2.4-19) [43]. Guided imagery/hypnotherapy also was effective in reducing pain intensity and frequency and reducing missed activities. In long-term follow-up from one trial [45], the beneficial effects of guided imagery/hypnotherapy were sustained for five years [60].
A subsequent trial, in which 260 children with FAPDs (age range 8 to 18 years) were randomly assigned to three months of self-administered home-based gut-directed hypnotherapy using a compact disc or individual gut-directed hypnotherapy with a qualified therapist, confirmed the effectiveness of both hypnotherapy approaches [57]. Although self-directed hypnotherapy was less effective than therapist-directed hypnotherapy at three months, outcomes at one and six years were similar [57,61]. Self-directed hypnotherapy may be an appealing option for older children and adolescents accepting of the self-administered approach, particularly if trained therapists are not available.
●CBT – CBT is a psychotherapy approach that identifies links between behavior, thoughts, and feelings to effect therapeutic change [29,62]. An individual CBT program may include various combinations of education, relaxation, stress management, and behavior modification techniques [29,63]. Provision of CBT requires specialized training and is usually provided by a psychologist. (See "Overview of psychotherapies", section on 'Cognitive and behavioral therapies' and 'Behavior modification' above and 'Indications for referral' below.)
Thinking positively and avoidance of counterproductive coping strategies appear to be important targets for CBT. In an observational study of 117 children with FAP, children's and caregivers' confidence in the child's potential to cope with abdominal pain (ie, thinking positively) was associated with improved functioning and decreased abdominal pain, whereas passive coping strategies (eg, self-isolation, catastrophizing, and disengagement) were associated with more symptoms of anxiety and depression [64].
A 2022 systematic review of psychosocial interventions for children with FAPDs found moderate-certainty evidence of treatment success with CBT compared with no intervention (38 versus 15 percent; risk ratio 2.37, 95% CI 1.30-4.34; six trials, 324 children); treatment success was defined dichotomously, but different criteria were used in different trials [44]. The systematic review also found moderate-certainty evidence of decreased pain frequency and pain intensity with CBT compared with no intervention. There was low certainty in evidence for studies comparing CBT with other modalities (eg, educational support, hypnotherapy, guided imagery) due to imprecision and risk of bias from lack of blinding. In one of the included trials, children with FAPDs assigned to 10 weeks of internet-delivered CBT had greater improvements in symptom severity and quality of life than those assigned to usual treatment (eg, treatment within the health care and school systems, including medications); benefits persisted through 36 weeks of follow-up [62]. Internet-delivered CBT also produced substantial cost savings per patient and has the potential to increase the availability of cost-effective treatment for FAPDs.
●Other therapies
•Biofeedback – Biofeedback is a technique that provides a visual or auditory display of the physiologic responses to pain/anxiety (eg, heart rate, skin temperature) so that the effects of relaxation techniques can be externally validated [30,51,55].
•Yoga – Yoga is commonly used as a relaxation technique to lessen stress and anxiety [65,66]. A 2022 systematic review of three randomized trials comparing yoga or yoga therapy (a mixture of yoga poses, meditation, and relaxation exercises) with no intervention in a total of 127 children with FAPDs did not detect a benefit with yoga on pain, quality of life, or daily activities [44,65,67,68]. However, in a subsequently published randomized trial, a combination yoga/dance intervention twice weekly for eight months was superior to standard care in reducing maximum pain in 121 females age 9 to 13 years with FAPDs [69]. Given the limited evidence, we do not suggest yoga as a routine intervention in the management of children and adolescents with FAPDs.
MANAGEMENT OF TRIGGERS — Avoidance of triggers may be beneficial in the management of functional abdominal pain disorders (FAPDs) in children and adolescents if triggers can be identified. Triggers may be identified by asking about aggravating and relieving factors or by asking the patient to keep a pain diary. (See "Chronic abdominal pain in children and adolescents: Approach to the evaluation", section on 'History'.)
Dietary triggers
●Eating in general – Among patients with FAPDs and visceral hypersensitivity, the act of eating may be associated with onset of pain. It is common for patients, particularly adolescents, to skip meals to avoid symptoms [70]. This practice should trigger suspicion of an eating disorder when the adolescent also has weight loss and constipation. (See "Anorexia nervosa in adults and adolescents: Medical complications and their management", section on 'Gastrointestinal'.)
●Specific triggers – We suggest not routinely restricting the diet of children with FAPDs. By definition, children with FAPDs do not have food allergy, which is typically excluded by the absence of other characteristic findings (eg, urticaria, oropharyngeal symptoms). High-certainty evidence of benefit is lacking, and restricted diets may result in nutrient deficiencies [71]. (See "Chronic abdominal pain in children and adolescents: Approach to the evaluation" and "Clinical manifestations of food allergy: An overview" and "Diagnostic evaluation of IgE-mediated food allergy".)
However, on a case-by-case basis, if there seems to be a correlation of symptoms with specific food triggers, a time-limited trial of elimination of the trigger(s) may be warranted [9]. Specific dietary triggers include citrus, caffeine, sorbitol (found in sugar-free candy and gum), and gas-producing foods (eg, beans, onions, celery, carrots, raisins, bananas, apricots, prunes, Brussels sprouts, wheat germ) [72].
It can be difficult to identify specific dietary triggers in children with FAPDs. Although they identify a variety of foods that exacerbate their symptoms (spicy foods, cow's milk, pizza, fried foods, fast foods, sodas, cheese, ice cream, and salsa are most commonly reported), they do not consistently identify a single food or ingredient (eg, wheat, lactose) [73,74]. In addition, dietary restriction may result in nutrient deficiencies; clinicians must take care to ensure that the restricted diet provides adequate nutrition. Consultation with a dietitian may be warranted.
Potential specific triggers include:
•Lactose – A trial of a lactose-free diet may be warranted if symptoms are consistent with lactose intolerance (eg, cramping pain, bloating, or gas related to ingestion of lactose). A lactose-free diet can be achieved by eliminating milk and milk products or by using lactase enzyme replacements. Patients who eliminate milk and milk products should be educated about adequate calcium and vitamin D intake. Lactose should be reintroduced if symptoms do not improve after two weeks of lactose elimination. Lactose avoidance may be continued in children whose symptoms improve during a lactose-free diet. For those patients in whom the benefit of lactose avoidance is unclear, it may be helpful to do a lactose hydrogen breath test. (See "Lactose intolerance and malabsorption: Clinical manifestations, diagnosis, and management", section on 'Management' and "Lactose intolerance and malabsorption: Clinical manifestations, diagnosis, and management", section on 'Malabsorption testing by hydrogen breath test'.)
Whether a lactose-free diet decreases the frequency of pain attacks for children and adolescents with FAPDs is uncertain [75]. Studies evaluating the effects of a lactose-free or low-lactose diet in children with FAPDs have had mixed results [76-79].
•Gluten/wheat – Patients with FAPDs may attribute their symptoms to carbohydrates other than lactose [80]. Gluten-free diets have become popular with increased concerns about the role of gluten sensitivity or celiac disease in chronic abdominal pain [70,81]. However, celiac disease is a rare cause of chronic abdominal pain in children. In a prospective study, only 1 out of 227 children ≥5 years of age with recurrent abdominal pain was found to have celiac disease [82]. (See "Diagnosis of celiac disease in children", section on 'Diagnosis'.)
Nonceliac gluten sensitivity (also called wheat intolerance syndrome) may be associated with gastrointestinal symptoms in a small subset of children [83]. In a prospective multicenter study in 1114 children with chronic gastrointestinal symptoms, symptoms correlated with gluten in 36 (3.3 percent); among the 28 who underwent randomized double-blind, placebo-controlled crossover gluten challenge, 11 reacted positively [84]. Wheat and gluten have also been associated with gastrointestinal symptoms in adult irritable bowel syndrome (IBS) patients without evidence of celiac disease [85,86]. Further understanding of the prevalence and mechanism of nonceliac wheat sensitivity is needed before gluten avoidance can be recommended for children and adolescents with FAPDs. Randomized trials of gluten avoidance in children with FAPDs are lacking [87].
•FODMAPs – FODMAPs are another group of carbohydrates that are considered potential triggers of FAPDs. FODMAPs are short-chain carbohydrates that are poorly absorbed by the gastrointestinal system and can lead to gas production, distention of the large intestine, bloating, and abdominal pain [79]. There is some evidence that a diet low in FODMAPs may be helpful in adults with IBS. (See "Treatment of irritable bowel syndrome in adults", section on 'Low FODMAP diet'.)
However, information on the role of FODMAPs in FAPDs in children is limited [14]. Several studies that focused on intolerance to fructose in children with FAPDs reported improvement in pain with fructose restriction, but these studies did not include a control group [88-90]. In a randomized crossover trial of 48 hours of a low- versus high-FODMAP diet in 33 children (7 to 17 years) with IBS, the low-FODMAP diet was associated with some improvement in gastrointestinal symptoms (eg, bloating, nausea) and decreased breath hydrogen production [91,92]. Mean pain severity scores decreased on both diets compared with baseline.
Although there is insufficient evidence for or against the efficacy and safety of routinely using a low-FODMAP diet for the management of children with FAPD [93], excessive gas formation is a potential indication.
Dietary restrictions in children should be implemented in consultation with a dietician because they may affect nutritional adequacy [70], be difficult to adhere to, and promote distorted eating in vulnerable children and adolescents. In adults, the low-FODMAP diet typically includes three phases: comprehensive elimination (usually for two to six weeks); reintroduction (during which individual FODMAP carbohydrates are used to determine which ones are most associated with symptoms); and personalization (tailoring the low-FODMAP diet to primarily avoid FODMAP triggers previously identified) [94]. Alternatively, a simplified version of the diet, called a "FODMAP-gentle diet" or "bottom-up approach," that initially excludes only a few foods with high concentrations of FODMAPs and gradually eliminates additional FODMAP products from the diet until the symptoms are alleviated has been proposed in children to avoid over-restriction and/or improve adherence [93].
Anxiety — Identification of coexisting anxiety in patients with FAPDs is critical. Anxiety disorders are estimated to affect 42 to 85 percent of pediatric patients with FAPDs [95-97]. It is important to explain to the patient and caregivers that screening for anxiety does not imply that the FAPD is a manifestation of a psychological disorder but rather that anxiety and the FAPD may coexist due to shared causative factors or as a consequence of coping with chronic pain [37]. In addition, there is evidence that anxiety may be associated with higher levels of functional impairment in children and adolescents with FAPDs [16].
Several nonpharmacologic therapies can be used to try to mitigate the physiologic effects of anxiety, including abdominal pain [21]. (See 'Improved coping' above.)
Nonpharmacologic therapies are an excellent way for caregivers to assess for anxiety and/or depression. Follow-up visits allow the caregivers, primary care provider, and, at times, the adolescent explore anxiety and/or depression as triggers of abdominal pain and nausea. Confirmation of anxiety and/or depression in this context sets the stage for the next step in management (ie, referral to a therapist for evaluation for anxiety/depression). If a therapist is already involved, discussion between the primary care provider and therapist can facilitate decisions regarding the need for medication (eg, selective serotonin reuptake inhibitor [SSRI]) and/or adjustments to counseling and other psychosocial interventions.
Referral to a psychiatrist is indicated if the therapist suggests medication. Alternatively, the primary care provider may prescribe an SSRI (eg, fluoxetine) if they have experience comanaging anxiety and/or depression in children and adolescents with a therapist. Close follow-up for side effects and response is recommended. (See "Pediatric unipolar depression and pharmacotherapy: Choosing a medication".)
MANAGEMENT OF SYMPTOMS
Abdominal pain — Medical interventions that may be combined with general behavioral management strategies for the management of abdominal pain in children with functional abdominal pain disorders (FAPDs) include probiotics, supplementation with water-soluble fiber (eg, psyllium/ispaghula husk), or peppermint oil. Although these interventions have not been well established in treatment algorithms, they have low risk of harm and short-term trials are reasonable. These interventions may be tried in any order or combination. We typically start with probiotics in patients with normal bowel movements and probiotics plus fiber in patients with constipation.
●Probiotics – Probiotics combined with general management strategies may be helpful in the management of abdominal pain, but the mechanism of action is not clear. Alterations to commensal bacterial populations have been implicated in dysmotility, visceral hypersensitivity, abnormal colonic fermentation, and immunologic activation. Probiotics may improve gastrointestinal symptoms by restoring the microbial balance in the gut through metabolic competition with pathogens, by enhancing the intestine's mucosal barrier, or by altering the intestinal inflammatory response [98].
The most effective probiotic strain, dose, or treatment duration has not been established [99,100]. Given that probiotics generally are safe [101], the decision to use a probiotic is typically based on the potential benefits, costs, and patient/family preferences. When the decision is made to try probiotics, we suggest commercial preparations of strains that have some evidence of benefit in gastrointestinal disease (eg, Lactobacillus reuteri DSM 17938 at a dose of ≥108 colony-forming units per day) [102]. We suggest that the probiotic be tried for four to six weeks before reassessment of symptoms of abdominal pain and/or abnormal bowel movements.
A 2023 meta-analysis of six randomized trials in 554 children with FAP found that probiotics were more effective than placebo for treatment success (50 versus 33 percent; risk ratio 1.57, 95% CI 1.05-2.36), based on low-certainty evidence [100]. The analysis was unable to determine whether probiotics are more effective than placebo for complete resolution of pain. It was also unable to distinguish between effectiveness of different probiotics, but most of the data were on L. reuteri or Lactobacillus rhamnosus GG. Although no cases of serious adverse events were reported, no conclusions can be drawn due to the low level of certainty due to imprecision from very low numbers and risk of bias.
●Fiber – For children with FAPDs and altered bowel movements, supplementation with water-soluble fiber may be warranted in addition to general management strategies. The exact mechanisms by which fiber may improve abdominal pain are not well understood but may include modification of intestinal microbiota, altered composition of stool and gas, and/or accelerated gastrointestinal transit [103]. Benefits of fiber supplementation should be weighed against the low but potential risk of increased bloating and pain.
The optimal dose, fiber type, and treatment duration for use in children with abdominal pain has not been established. We generally suggest using a water-soluble fiber (eg, psyllium hydrophilic mucilloid [ispaghula husk]) at a dose of 1.5 to 12.5 grams per day, depending on the patient's size and baseline dietary intake of fiber. A reasonable target for total dietary fiber intake is the child's age in years plus 5 to 10 grams per day. We continue the trial of fiber supplementation for at least four weeks before determining whether there has been an improvement in abdominal pain frequency and severity.
A 2022 systematic review of five randomized trials that compared fiber supplementation with placebo in 385 children ages 4 to 18 years with FAPDs concluded that water-soluble fibers, particularly psyllium, may provide a slight benefit [104].
Recommendations regarding fiber intake in children with chronic functional constipation and fecal incontinence are discussed separately. (See "Dietary recommendations for toddlers and preschool and school-age children", section on 'Fiber' and "Chronic functional constipation and fecal incontinence in infants, children, and adolescents: Treatment", section on 'Dietary changes'.)
●Peppermint oil – Peppermint oil is another intervention that may be helpful in combination with general management strategies in the management of abdominal pain in children with FAPDs [14,105,106]. (See 'General management strategies' above.)
Although the evidence is limited, peppermint oil is thought to decrease smooth muscle spasms in the gastrointestinal tract [21]. A 2022 systematic review of pharmacologic treatments for FAPDs in children included two randomized controlled trials evaluating two to four weeks of treatment with peppermint oil and found low-certainty evidence that peppermint oil reduced pain severity, duration, and frequency compared with placebo or lactol (Bacillus coagulans plus fructooligosaccharides) [107-109]. No patients discontinued treatment due to adverse events. A 2011 meta-analysis of randomized trials in patients >12 years of age concluded that peppermint oil was effective in the treatment of irritable bowel syndrome (IBS) [105].
Peppermint oil capsules are available commercially. In both of the included trials, peppermint oil was administered as a pH-dependent enteric coated capsule (187 mg three times per day for children weighing <45 kg; 374 mg three times per day for children weighing >45 kg). Excessive intake of peppermint oil may lead to exacerbation of gastroesophageal reflux and has been associated with interstitial nephritis and acute renal failure [110,111].
●Other antispasmodics – Other antispasmodics include drotaverine, mebeverine, trimebutine, hyoscyamine, and dicyclomine. While antispasmodic medications are superior to placebo in the treatment of adults with IBS [112], few studies have evaluated the effectiveness of antispasmodics in the treatment of childhood FAPDs [108,113]. A 2022 systematic review of pharmacologic treatments for FAPDs in children included three randomized controlled trials evaluating three to four weeks of treatment with other antispasmodics (drotaverine, mebeverine, trimebutine) and found low-certainty evidence that these agents improve treatment success and decrease pain episodes [108,114-116]. Three participants discontinued mebeverine for adverse effects (drowsiness, nervousness, nausea), and one participant discontinued drotaverine due to urticaria [108].
The long-term use of other antispasmodic medications in children may be limited by anticholinergic side effects (eg, dry mouth, blurred vision) [21]. Additional studies of safety and efficacy are necessary before antispasmodic medications can be routinely recommended for children with FAPDs.
●Other interventions
•Antidepressants – We suggest not routinely prescribing antidepressants for children and adolescents with FAPDs unless they meet diagnostic criteria for associated depression. (See "Pediatric unipolar depression: Epidemiology, clinical features, assessment, and diagnosis", section on 'Diagnosing depressive disorders'.)
A substantial proportion of abdominal pain in functional disorders is believed to be associated with abnormal perception of visceral sensations. Medications initially indicated for the treatment of depression and anxiety have been explored for the management of FAPDs because of their effects on central and enteric nervous system neurotransmitters, such as acetylcholine and serotonin. However, studies of these agents in children and adolescents with FAPDs are limited and it is uncertain whether antidepressants are beneficial in the treatment of FAPDs in children [117].
•Cyproheptadine – Cyproheptadine is a medication with multiple mechanisms, including antihistaminic, anticholinergic, and antiserotonergic properties as well as possible calcium channel blockade effects. It has been used in appetite stimulation and prevention of pain and vomiting in abdominal migraine and cyclic vomiting syndrome. In retrospective studies, cyproheptadine has been reported to be safe and effective for the treatment of FAPDs and dyspeptic symptoms in children [118,119]. In a randomized trial of 29 children and adolescents with FAPDs, 86 percent of the group treated with cyproheptadine for two weeks had improvement or resolution of abdominal pain compared with 35.7 percent in the placebo group [120]. These results need to be confirmed with larger, additional trials before cyproheptadine can be routinely recommended for the treatment of FAPDs [18].
•Auricular neurostimulation therapy – In auricular neurostimulation therapy, percutaneous electrical nerve field stimulation (PENFS) is administered through a noninvasive device that is worn behind the ear to target central pain pathways involved in pain amplification [121]. In a randomized sham-controlled trial in 115 adolescents, auricular neurostimulation reduced abdominal pain severity, frequency, and duration with no serious adverse effects in adolescents with FAPDs [122]. In another randomized sham-controlled trial in 50 adolescents with IBS, auricular neurostimulation reduced abdominal pain scores and improved overall well-being [121]. In addition to improvements in self-reported symptoms of abdominal pain and nausea, PENFS has been associated with changes in visceral sensitivity using a water load task, actigraphic and subjective sleep measures, and other psychological factors like catastrophizing and somatic complaints [123].
Although these findings are promising and the US Food and Drug Administration has granted permission to market the device for relief of FAP in 11- to 18-year-old adolescents with IBS, additional studies are necessary to confirm the results, determine the optimal setting and duration of treatment, and determine the optimal target population before PENFS can be routinely recommended for children with FAPDs [14,122,124,125].
Dyspepsia — Dyspepsia is pain or discomfort that is centered in the epigastric region or upper abdomen. Discomfort may be characterized by fullness, early satiety, bloating, nausea, retching, or vomiting [7]. The pain or discomfort may be exacerbated by eating. Dyspepsia is the predominant symptom in children with functional dyspepsia (table 2).
We suggest the following interventions for symptomatic management of functional dyspepsia [9]:
●Small, frequent meals
●Avoidance of foods, beverages, and medications that aggravate symptoms (eg, high-fat foods, caffeinated beverages, nonsteroidal antiinflammatory drugs) [20] (see 'Dietary triggers' above)
We suggest not routinely using pharmacologic therapy (eg, H2 blockers, proton pump inhibitors) for children and adolescents with functional dyspepsia. A 2022 systematic review of pharmacologic therapy for FAPDs in children included only one randomized trial with inconclusive results [108,126]. However, for children and adolescents with severe symptoms unresponsive to nonpharmacologic therapies, a trial of an H2 blocker (cimetidine, famotidine; ranitidine has been withdrawn from the market in the United States and Australia [127,128]) or a proton pump inhibitor (lansoprazole, esomeprazole) for four to six weeks may be warranted [9,129,130]. The medication should be discontinued if there is no improvement.
We suggest not routinely using prokinetic agents (eg, metoclopramide, domperidone, erythromycin) in the treatment of children and adolescents with FAPDs. There is little evidence of efficacy and potential for adverse effects, particularly with metoclopramide and domperidone [9,21,131].
Diarrhea — Diarrhea may be the predominant symptom in children with IBS (table 2). Children and adolescents whose diarrhea consists of ≥3 loose or watery stools per day for more than two weeks (which is an alarm symptom) require evaluation for organic disease. (See "Chronic abdominal pain in children and adolescents: Approach to the evaluation", section on 'Patients with alarm findings'.)
From a practical standpoint, it may be helpful for the clinician to provide a note to the school requesting that the child or adolescent with FAPD and diarrhea be allowed to use the bathroom whenever necessary [9,12]. In addition, it is important for the patient to maintain adequate fluid intake.
We suggest not routinely restricting the diet of children with FAPD and diarrhea. However, on a case-by-case basis, if there seems to be a correlation of diarrhea with a specific food trigger (eg, lactose, sorbitol), a time-limited trial of elimination of the trigger may be warranted [9]. (See 'Dietary triggers' above.)
We suggest not routinely using antimotility agents for children or adolescents with FAPD and diarrhea. The diarrhea associated with FAPDs is typically of short duration, and antimotility agents generally are not recommended for the management of other types of diarrhea (eg, infectious, antibiotic-associated) in children.
Constipation — Identification of underlying constipation is critical for patients with FAPD. The treatment of constipation in children is discussed separately. (See "Chronic functional constipation and fecal incontinence in infants, children, and adolescents: Treatment", section on 'Treatment of constipation in children'.)
Unproven interventions
●Open-label placebo – In placebo-controlled trials in children with FAPDs, the response to placebo is substantial [19], which may be related to the natural history of improvement over time, regression to the mean, methodologic factors, and contextual factors (eg, expectations and conditioning) [14]. Although it was traditionally believed that blinding of patients was necessary to elicit a placebo response, studies in adult patients with IBS suggest a placebo response even when the placebo is administered openly [132,133]. In a subsequent crossover trial in which 30 children and adolescents with FAPDs were randomly assigned to three weeks of open-label placebo (an inert oral suspension) or a three-week control period, mean pain scores (39.9 versus 45.0) and mean number of doses of rescue medication (2.0 versus 3.8) were lower during the open-label placebo period [134]. These results suggest that open-label placebo may reduce pain in children with FAPDs, but additional studies are necessary before open-label placebo can be recommended.
●Other unproven interventions – A number of other interventions are used in adults with pain-predominant functional gastrointestinal disorders or have been tried in children with FAP but lack clear evidence of benefit in randomized trials. These include rifaximin [135,136], linaclotide, lubiprostone, otilonium bromide (available outside of the United States), fennel, licorice, ginger, and Iberogast (an herbal therapy) [137]. (See "Treatment of irritable bowel syndrome in adults".)
FOLLOW-UP — Children and adolescents with functional abdominal pain disorders (FAPDs) require regular follow-up to maintain the therapeutic relationship, provide continued education and reassurance, monitor the response to intervention, and monitor the development of alarm findings (table 1) [11,12,39].
Children with persistent abdominal pain that affects patient and family function may benefit from referral to a mental health provider, other specialist, or multidisciplinary clinic [24]. (See 'Indications for referral' below.)
Children who develop alarm findings (table 1) require evaluation for organic disease. (See "Chronic abdominal pain in children and adolescents: Approach to the evaluation", section on 'Patients with alarm findings'.)
INDICATIONS FOR REFERRAL
●Alarm findings – Children who develop alarm findings (table 1) may require referral to a gastroenterologist or other specialist for evaluation and/or management. (See "Chronic abdominal pain in children and adolescents: Approach to the evaluation", section on 'Patients with alarm findings'.)
●Abdominal pain-associated disability – Children with abdominal pain-associated disability (eg, missed school or extracurricular activities, anxiety, depression) may benefit from referral to a mental health provider for counseling or therapy and rehabilitation, including cognitive behavioral therapy (CBT).
Referral to a developmental-behavioral pediatrician (for younger children), adolescent medicine specialist (for teenagers), mental health provider, or multidisciplinary clinic may be helpful in providing strategies for return to activities of daily living and avoiding ongoing pain-induced disability [10,12,24,75].
Some patients and families, particularly those who continue to focus on the search for an organic etiology, may be resistant to referral to a therapist or counselor. The pediatric care provider can facilitate referral by explaining to the family their limitations in management without further assistance from a therapist. The provider should discuss the potential benefit to the family from counseling sessions with a therapist who can help the child cope with the pain and can support the necessary changes in the child's life (eg, return to school).
●Refractory constipation – Children with constipation that does not respond to primary care interventions may benefit from referral to a gastroenterologist. (See "Chronic functional constipation and fecal incontinence in infants, children, and adolescents: Treatment".)
PROGNOSIS — Functional abdominal pain disorders (FAPDs) resolve in the majority of children [16,17,138]. In a systematic review of 18 prospective studies including 1331 children with chronic abdominal pain, abdominal pain persisted in 29.1 percent (95% CI 28.1-30.2) at median follow-up of five years (range 1 to 29) [17]. In a prospective study of 132 children with FAPDs followed in a gastroenterology clinic, symptoms improved in approximately 85 percent of patients by two months and improvement was maintained at one and five years [16].
Factors associated with improvement of abdominal pain in observational studies include caregiver acceptance of a biopsychosocial model of illness, low levels of symptoms and impairment at the time of presentation, and rapid improvement in symptoms in patients with high levels of symptoms and impairment at the time of presentation [16,23].
Factors associated with persistent functional pain include caregiver modeling and reinforcement of the sick role, family members with chronic pain disorders, age younger than six years at the time of diagnosis, more than six months' duration of pain before seeking treatment, negative life events, and increased symptoms of anxiety and depression [16,20,21,139].
Some longitudinal studies suggest that children with FAP-not otherwise specified (FAP-NOS) go on to have irritable bowel syndrome (IBS) as adults [140-142]. In a longitudinal study of 392 patients diagnosed with FAP-NOS following a specialty clinic evaluation at age 8 to 16 years, 41 percent met symptom criteria for a functional gastrointestinal disorder at follow-up 5 to 15 years later (average 9.2 years) [142]. IBS and functional dyspepsia were the most frequent functional gastrointestinal disorders. After controlling for age, sex, and severity of abdominal pain at the time of diagnosis, a functional gastrointestinal disorder at follow-up was associated with extraintestinal somatic and depressive symptoms.
Other prospective studies indicate that children with a history of FAP-NOS are at risk for anxiety or depression in adolescence and adulthood [35,143-145]. In a prospective study in which 322 children with FAPDs were followed to young adulthood (mean age 20 years), the lifetime risk of anxiety and depression were 51 and 40 percent (versus 20 and 16 percent in controls) [35].
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Chronic abdominal pain in children".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient education" and the keyword[s] of interest.)
●Beyond the Basics topic (see "Patient education: Chronic abdominal pain in children and adolescents (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Terminology – Functional abdominal pain disorders (FAPDs) can be diagnosed in children who have all of the following:
•Chronic (≥2 months) abdominal pain
•No alarm findings (table 1)
•Normal physical examination
•Stool sample negative for occult blood
Several functional gastrointestinal disorders of childhood have recognizable patterns of symptoms, including irritable bowel syndrome (IBS), functional dyspepsia, and abdominal migraine (table 2). (See 'Terminology' above.)
●Management approach – The goal of management of FAPDs in children and adolescents is return to normal function rather than complete elimination of pain (a rehabilitation approach). Management is individualized according to child and family behavior, triggers, and symptoms. Most cases can be managed in the primary care setting. (See 'Management approach' above.)
●General management strategies
•FAPDs are best treated in the context of a biopsychosocial model of care (figure 1). The patient and family must believe that their complaints and concerns are taken seriously. Establishing a therapeutic relationship, patient and family education, and a plan for return to school are important components of management. (See 'Therapeutic relationship' above and 'Patient education' above and 'Return to school' above.)
•Return to normal function is facilitated by reinforcement of nonpain (healthy or adaptive) behaviors and avoiding reinforcement of pain or pain (sick, illness, maladaptive) behaviors. (See 'Behavior modification' above.)
•We suggest psychological interventions (eg, relaxation, distraction, guided imagery, cognitive behavioral therapy [CBT] (table 3)) to improve coping and decrease stress/anxiety in children and adolescents with FAPDs (Grade 2B). (See 'Improved coping' above.)
●Dietary triggers – We suggest not routinely restricting the diet of children and adolescents with FAPDs (Grade 2C). However, on a case-by-case basis, a time-limited trial of avoidance of specific dietary triggers (eg, lactose, sorbitol) may be warranted. (See 'Dietary triggers' above.)
●Management of symptoms
•Medical interventions that may be combined with behavioral interventions include a trial of probiotics, supplementation with water-soluble fiber (eg, psyllium/ispaghula husk), or peppermint oil. These interventions may be tried in any order or combination. We typically start with probiotics in patients with normal bowel movements and probiotics plus fiber in patients with constipation. (See 'Abdominal pain' above.)
•We suggest small frequent meals and avoidance of foods, beverages, and medications that aggravate symptoms rather than pharmacologic therapy for the initial management of functional dyspepsia (Grade 2C). (See 'Dyspepsia' above.)
•We suggest not routinely using antimotility agents for children or adolescents with FAP and diarrhea (Grade 2C). (See 'Diarrhea' above.)
●Follow-up and indications for referral – Regular follow-up is necessary to maintain the therapeutic relationship, provide continued education and reassurance, monitor the response to intervention, and monitor the development of alarm findings. (See 'Follow-up' above.)
Children with persistent abdominal pain that affects patient and family function may benefit from referral to a mental health provider or other specialist. Children who develop alarm findings (table 1) require evaluation for organic disease. (See 'Indications for referral' above and "Chronic abdominal pain in children and adolescents: Approach to the evaluation", section on 'Patients with alarm findings'.)
●Prognosis – FAPDs resolve over several months in the majority of children. (See 'Prognosis' above.)
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