Version July 2025
INTRODUCTION —
Functional abdominal pain disorders, also called disorders of gut-brain interaction (DGBIs) or pain-predominant functional gastrointestinal disorders, are the most common cause of chronic abdominal pain in children and adolescents [1].
These disorders involve interplay among regulatory factors in the enteric and central nervous systems [2]. They may be associated with visceral hyperalgesia, reduced threshold for pain due to central dysregulation of visceral afferent input, abnormal pain generated after rectal distension in irritable bowel syndrome (IBS), or impaired gastric relaxation response to meals [3-7]. 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 DGBIs is reviewed here. The evaluation of children and adolescents with chronic abdominal pain is discussed separately. (See "Chronic abdominal pain in children and adolescents: Approach to the evaluation".)
Functional gastrointestinal disorders in adults are discussed separately. (See "Functional dyspepsia in adults" and "Clinical manifestations and diagnosis of irritable bowel syndrome in adults" and "Treatment of irritable bowel syndrome in adults".)
TERMINOLOGY
●Disorders of gut-brain interaction (DGBIs) – This term is increasingly used instead of "functional gastrointestinal disorders" to describe a group of disorders related to any combination of the following factors: visceral hypersensitivity, motility disturbance, altered mucosal and immune function, altered gut microbiota, and altered central nervous system processing [8], and without any readily identifiable well-defined organic condition. The new terminology emphasizes the bidirectional interplay between the enteric and central nervous systems and that gastrointestinal and psychosocial factors contribute to symptoms [9]. There is also less focus on the dichotomy between "organic" disorders, which are implied by some as being more "real," compared with "functional" disorders, which can be considered psychiatric, undefined, or less legitimate. The terminology, however, is still in transition, and some of the subcategories retain the word "functional" in their name. (See "Chronic abdominal pain in children and adolescents: Approach to the evaluation", section on 'Terminology'.)
These disorders are categorized into four subtypes (table 1):
•Functional dyspepsia
•Irritable bowel syndrome (IBS)
•Abdominal migraine
•Functional abdominal pain not otherwise specified (FAP-NOS)
Functional constipation is grouped separately as a functional defecation disorder but is a consideration when evaluating symptoms of chronic abdominal pain.
●Functional abdominal pain-not otherwise specified (FAP-NOS) – FAP-NOS may be diagnosed in children who have the following features for at least two months [10] and do not meet specific criteria for the other types of DGBIs (functional dyspepsia, IBS, or abdominal migraine) (see "Chronic abdominal pain in children and adolescents: Approach to the evaluation", section on 'Diagnosis of a disorder of gut-brain interaction'):
•Episodic or continuous abdominal pain that does not occur solely during physiologic events such as eating or menses
•No alarm findings (table 2)
•Normal physical examination
•After appropriate evaluation, the pain cannot be fully explained by another medical condition
•Stool sample negative for occult blood (if available and approved for office use; not required for the diagnosis of FAP-NOS)
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." Current guidance suggests not using "recurrent abdominal pain of childhood" as a diagnosis, because it is a heterogenous symptom complex with both organic and functional etiologies [11,12].
MANAGEMENT APPROACH —
Most cases of functional abdominal pain 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.)
●Goals and expectations – The goal of management of disorders of gut-brain interaction (DGBIs; also known as functional abdominal pain disorders) in children and adolescents is return to normal function (ie, rehabilitation) rather than complete elimination of pain [2,11,14-16]. To this end, it is helpful to elicit the following information in the first meeting with new patients:
•What does the patient (or family) think is causing their symptoms?
•What are their fears or concerns?
•What do they expect from the clinician or from treatment?
Discussing these three points provides a foundation for a potentially successful treatment partnership [17]. (See 'Therapeutic relationship' below.)
●Individualized strategies – The management of DGBIs is challenging because the subtypes are heterogeneous and the pathophysiology is incompletely understood. Individuals with DGBIs may have similar symptoms (eg, abdominal pain, nausea, changes in bowel movements) but different underlying causes. Thus, management should be individualized according to the child's and family's behaviors, triggers, symptoms, and progress [18,19].
●Role of placebo response – DGBIs have a high response rate to placebos. This can be a valuable therapeutic tool strategy but does not indicate that the patient's symptoms are not valid. In addition, these disorders resolve with time in the majority of children [20-22]. Thus, a response to any intervention may reflect either a placebo response or the natural history of improvement over time.
A high placebo response rate was demonstrated 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 for complete pain relief was 17 percent (95% CI 8-32 percent) [23]. The study did not identify specific factors that could be used in clinical practice to optimize the placebo response. (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 [11].
GENERAL MANAGEMENT STRATEGIES —
The approach to disorders of gut-brain interaction (DGBIs; also known as functional abdominal pain disorders) 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 [11,24]. For patients whose pain remains unrelenting and continues to interfere with functioning, referral for noninvasive interventions such as hypnotherapy, guided imagery [25], 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 DGBIs. The patient and family must believe that their complaints and concerns are taken seriously [24,26]. 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 can proceed [16].
The biopsychosocial model of abdominal pain provides a framework for understanding and managing DGBIs (figure 1). It is a valuable part of educating the patient and family about DGBIs and provides reassurance about the likely cause(s) of the symptoms and management strategies. Use of analogies (such as the experience of feeling nauseated in anticipation of taking a test) may help the family better understand the nature of "functional" pain. (See 'Patient education' below.)
The patient and family may be reassured by the clinician's acknowledgment that the pain is real and has affected important activities in the patient's life. The tone should be nonjudgmental and patient. Treatment goals should be clearly defined and agreed upon by the patient and clinician [17]. The clinician should set expectations for ongoing care with follow-up, which permits reassessment and adjustments to management as needed and also demonstrates 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. In many cases, this means prescribing and supporting a return to structured activities of daily living, including school attendance (a rehabilitative approach that may involve progressing from partial to full attendance). Similarly, the clinician should acknowledge the stress that other family members experience because of the child's symptoms and provide support and guidance for addressing this stress. (See 'Return to school' below.)
Some centers have developed a multidisciplinary model of care for patients with DGBIs, usually including a pediatric gastroenterologist, pain specialist, and psychologist. The multidisciplinary team reinforces the biopsychosocial aspects of DGBIs, demonstrates that the patient's and family's concerns are being taken seriously, and incorporates the psychologist as an essential member rather than as an approach of last resort. In observational studies, multidisciplinary care has been associated with reduced pain, increased function, and decreased health care utilization in children with DGBIs [27,28].
Patient education
●Explaining the causes of the symptoms – DGBIs are best treated in the context of a biopsychosocial model of care (figure 1) [11,29-34]. This model can be described to the patient and family in lay terms as an interaction between:
•Biologic factors that affect someone's experience of pain (such as inflammation, movements of the intestine, or differences in pain sensation thresholds)
•Environmental triggers that can make the symptoms better or worse (such as diet or medications)
•Emotional and social factors (such as anxiety, life stressors, social support, or coping skills)
This explanation can be helpful because it frames the child's symptoms as a positive diagnosis with specific treatment strategies, rather than a diagnosis of exclusion (which implies an 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 [35]. (See 'Prognosis' below.)
●Setting realistic expectations – Before beginning therapy, the clinician should clarify the expectations of the caregivers and patient. Some caregivers may simply want assurance that the pain is not caused by an organic illness with potentially serious health consequences. In other cases, the clinician can guide the family to set realistic goals, such as improved function, improved tolerance of symptoms, and return to normal activity and school attendance despite ongoing discomfort (a rehabilitative approach) [11,14,16,24].
●Specific education points to emphasize:
•This type of abdominal pain is 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 is not life-threatening and does not require activity restriction.
•The pain 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, this type 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) [15,24,36,37]. Other examples of physiologic responses to stress or anxiety include headaches, churning of the stomach before a test, and nausea when given bad news.
•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 [16].
•Chronic pain, regardless of the etiology, can be associated with depression or anxiety (both as a cause and an effect) [38]. (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 [39]. 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 the DGBI (even if the diagnosis is provisional) [16]. Caregivers who are concerned about their child's emotional reaction to returning to school may need help in formulating and implementing a plan for stepwise return to school. For example, the family can 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's and family's confidence in the child's ability to attend school [16].
Counseling to facilitate the return to school may include collaborative planning for [16,39]:
●How to manage any pain episodes that occur at school. For example, the child might be allowed to go to the nurse's office until pain subsides (with some limitations because, in some cases, frequent use of the nurse's office at school may reinforce symptoms).
●Specific conditions for deciding when the child is too sick to go to school or sick enough to be allowed to come home (eg, limiting sick days to fever, vomiting, or diarrhea). School absences for other reasons may reinforce symptoms and should be avoided.
●Activity restriction when the child remains home from school (eg, bedrest without television or other electronic entertainment).
●Identifying and addressing school-related sources of stress (eg, bullying, social isolation, inappropriate classroom placement).
●In addition, direct communications from the clinician to the school may be helpful in some cases:
•For children with 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, the clinician can send a letter to document that the child has undergone an evaluation for gastrointestinal symptoms that have interfered with attendance and is participating in a plan to return to school.
Behavior modification — To help the child return to normal function, parents and caregivers should learn to reinforce healthy (or adaptive) behaviors and avoid reinforcement of illness (pain-focused or maladaptive) behaviors [16,40]. Suggestions for behavior modification techniques may be provided by the primary care clinician and/or in a more formal psychotherapy program if necessary.
●Reinforce healthy (adaptive) behaviors – Examples include [16,37,41]:
•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).
•Highlighting and supporting the child's interests and skills outside of the sick role (eg, athletic, artistic, or academic pursuits).
•Caregiver modeling of healthy responses to abdominal pain (eg, deep breathing, self-distraction). (See 'Interventions to improve coping' below.)
●Avoid reinforcing illness (pain-focused) behaviors – In attempts to be supportive and nurturing, caregivers of children with DGBIs sometimes inadvertently reinforce/promote pain or illness behaviors [24,42]. Examples include [43]:
•Providing unnecessary attention to the pain (eg, asking frequently about symptoms). If the family finds it difficult to completely discontinue conversation about symptoms, scheduling a "symptom report" once per day may be helpful [16].
•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) [41].
•Allowing the child who stays home from school to watch television or have access to other forms of entertainment.
•Caregiver modeling of maladaptive responses to their own pain symptoms (eg, frequent discussion of pain or avoidance of activities). Modeling is important because children tend to express their pain in the same way as their parents behave with pain [44].
Interventions to improve coping — We suggest incorporation of psychological treatments to improve coping in the management of children and adolescents with DGBIs. Coping is defined as voluntary efforts to regulate emotion, thought, behavior, physiology, and the environment in response to stressful events or circumstances [45].
For children with DGBIs, learning coping techniques facilitates return to normal function. Few studies directly compare psychological interventions to improve coping with "standard pediatric care" (which typically involves education and reassurance with or without dietary interventions or pharmacotherapy) [46-51]. However, limited evidence from randomized and observational studies suggest that psychological interventions are associated with improved pain tolerance, reduced anxiety, increased healthy (adaptive) behaviors, and improved self-management [52-54]. (See 'Behavior modification' above.)
Supportive interventions (relaxation and distraction techniques, guided imagery and some forms of hypnotherapy) can be taught by trained primary care clinicians; psychological interventions (cognitive behavioral therapy [CBT] and biofeedback) typically require referral to mental health professionals with specialized training [55].
●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) [14]. 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 [24].
In observational studies and meta-analyses, relaxation therapy helped to reduce pain and improve function in children with DGBIs [41,56-58].
●Distraction techniques – Distraction consists of intentional activities to shift attention away from pain [59]. Activities may include conversation, games, television, mental arithmetic, or encouraging the child to use their imagination to think about pleasant things when confronted with pain [60]. 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 [61].
●Guided imagery or hypnotherapy – Guided imagery and hypnotherapy/self-hypnosis are distraction techniques through which the child engages in imagery and relaxation, which distracts attention from painful stimuli [47,62]. It is believed to act by normalizing altered visceral sensation, reducing colonic contractions, and reversing patients' negative thoughts about their condition. The child is guided to respond to suggestions toward control and normalization of gut functioning, stress reduction, and ego strengthening [60]. 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 [63].
In a 2017 meta-analysis of four small randomized trials including 146 children with recurrent abdominal pain [25,46,47,64], 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) [53]. Guided imagery/hypnotherapy also was effective in reducing pain intensity and frequency and reducing missed activities. In long-term follow-up from one trial [46], the beneficial effects of guided imagery/hypnotherapy were sustained for five years [65].
A subsequent trial, in which 260 children with DGBIs (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 [63]. Although self-directed hypnotherapy was less effective than therapist-directed hypnotherapy at three months, outcomes at one and six years were similar [63,66]. 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 helps a patient recognize the links between thoughts, feelings, and behaviors [31,67]. The goal of CBT is to develop more logical and adaptive beliefs and behaviors to help deescalate symptoms [68]. A CBT program may include various combinations of education, relaxation, stress management, and behavior modification techniques [31,69]. 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.)
As an example, the CBT therapist may ask the patient to describe or record their thought processes surrounding the experience of pain and identify any thoughts that are illogical. Then, the therapist helps the patient find a suitable strategy for responding to the pain (such as the distraction techniques described above) and has them practice the skill during therapy sessions [70].
Thinking positively and avoidance of counterproductive coping strategies are important targets for CBT. In an observational study of 117 children with DGBIs, 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, disengagement) were associated with more symptoms of anxiety and depression [71].
The efficacy of CBT for DGBIs is supported by a 2024 meta-analysis of 10 randomized trials, which found that CBT improved scores on standardized measures of physical quality of life (14.1 on a 100-point scale [95% CI 0.9 to 27], where a 4-point increase is considered clinically significant). There were also small and clinically insignificant improvements in functional disability (mean change -2.3 on a 60-point scale, 95% CI -4.5 to -0.03) and pain intensity (mean change -0.6 on a 10-point scale, 95% CI -1.15 to -0.04). The included studies used a variety of methods to deliver CBT (in person, internet, and phone) [72]. A prior meta-analysis with minimal overlap also found significant benefits of CBT on overall "treatment success" compared with no intervention (variously defined; 40 versus 15 percent; risk ratio 2.37, 95% CI 1.3-4.3), although specific benefits on pain frequency and intensity were small and probably not clinically significant [54]. These analyses are limited by risk of bias due to lack of blinding and imprecision due to low participant numbers.
●Other therapies – The following interventions have limited supportive evidence:
•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. Small randomized trials suggest that adjunctive biofeedback therapy may improve pain intensity and duration compared with medication alone [73] and enhance clinical improvement (a composite measure) compared with a dietary fiber intervention [74].
•Yoga – Yoga is commonly used as a relaxation technique to lessen stress and anxiety [75,76]. A 2022 meta-analysis (three trials, 127 participants) comparing yoga or yoga therapy (a mixture of yoga poses, meditation, and relaxation exercises) with no intervention in children with DGBIs did not detect a benefit with yoga on pain, quality of life, or daily activities [54]. 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 DGBIs [77]. Given the limited evidence, we do not suggest yoga as a routine intervention in the management of children and adolescents with DGBIs.
MANAGEMENT OF TRIGGERS —
If specific dietary triggers for a child's abdominal pain can be identified, a trial of avoidance of those triggers may be beneficial, with guidance from their primary care clinician to avoid adverse effects on diet quality or exacerbating food-related anxiety. 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 disorders of gut-brain interaction (DGBIs; also known as functional abdominal pain disorders) and visceral hypersensitivity, the act of eating may be associated with onset of pain. Such patients, particularly adolescents, often skip meals to avoid symptoms [78]. If they also have weight loss and constipation, further evaluation for an eating disorder is warranted. (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 DGBIs. High-certainty evidence of benefit is lacking, and restricted diets may result in nutrient deficiencies [79]. By definition, children with these disorders do not have food allergy, which is typically excluded by the absence of other characteristic findings (eg, urticaria, oropharyngeal symptoms). (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 an individual 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 [12]. Relatively common dietary triggers include citrus, caffeine, spicy foods, lactose, 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) [80,81]. In these patients, the dietary triggers may be causing a physiologic response (eg, intestinal gas, gastroesophageal reflux) that contributes to the functional abdominal pain.
It can be difficult to identify specific dietary triggers in children with DGBIs. Although the child may 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), in most cases, they are unable to identify a single food or ingredient (eg, wheat, lactose) [82,83]. 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 that is temporally 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 and intolerance testing'.)
Whether a lactose-free diet decreases the frequency of pain episodes for children and adolescents with DGBIs is uncertain [84]. Studies evaluating the effects of a lactose-free or low-lactose diet in this population have had mixed results [85-88].
•Gluten/wheat
-Celiac disease (limited association) – By definition, patients with DGBIs do not have celiac disease. Specific serologic testing for celiac disease is usually performed during the initial evaluation for chronic abdominal pain and is especially important for patients who perceive that gluten is a trigger for their symptoms (see "Diagnosis of celiac disease in children"). Testing for wheat allergy (serology or skin prick testing) is not warranted, except for children with symptoms consistent with an immunoglobulin E (IgE)-mediated food allergy (eg, symptom onset within minutes to two hours after ingestion, especially with rash or other signs of anaphylaxis). (See "Grain allergy: Clinical features, diagnosis, and management".)
When serologic testing for celiac disease is performed in children with symptoms suggesting a DGBI, celiac disease is diagnosed in approximately 2 to 4 percent, which is higher than in the general population (approximately 1 percent) [89]. Thus, children with apparent DGBIs have an increased risk of celiac disease, but the overall prevalence is low.
-Nonceliac gluten sensitivity (rare) – Even after celiac disease has been excluded by appropriate testing, some patients and families perceive that gluten is a trigger for the child's abdominal symptoms. In many cases, this may be related to the popularity of gluten-free diets to address a wide range of symptoms, including chronic abdominal pain. For most such individuals, gluten is probably not a trigger for their symptoms. However, a small minority may have "nonceliac gluten sensitivity" (or "wheat intolerance syndrome") [90]. This is a poorly defined syndrome characterized by a variable combination of intestinal and extraintestinal symptoms, typically occurring soon after the ingestion of gluten-containing foods and disappearing quickly upon their withdrawal. There is no reliable marker for nonceliac gluten sensitivity, and the only way to make a definitive diagnosis is with a blinded gluten challenge. As an example, in a prospective multicenter study in 1114 children with chronic gastrointestinal symptoms, 36 (3.3 percent) had symptoms that seemed to be correlated with gluten ingestion. Among the 28 who underwent randomized double-blind, placebo-controlled crossover gluten challenge, 11 reacted positively, representing approximately 1 percent who fit the criteria [91]. In a randomized, double-blind crossover study in adults with suspected nonceliac gluten sensitivity, improvement was attributed to avoidance of fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs) rather than gluten, suggesting that FODMAP sensitivity may mimic nonceliac gluten sensitivity [92]. (See "Epidemiology, pathogenesis, and clinical manifestations of celiac disease in children", section on 'Nonceliac gluten sensitivity'.)
-Counseling – We do not recommend routine use of a gluten-free diet for children with DGBIs. For most patients, gluten avoidance will not improve symptoms. However, if patients and families perceive that gluten is a trigger for their symptoms, serologic screening for celiac disease is indicated, if not already done. Note that the serologic testing for celiac disease should be performed when the patient is on a gluten-containing diet of appropriate duration. (See "Diagnosis of celiac disease in children", section on 'Pretesting diet'.)
If celiac disease is excluded, the family can be counseled that a gluten-free diet is unlikely to improve symptoms. If the informed family and child still want to try a gluten-free diet, it is reasonable to support them in this endeavor but with monitoring to ensure that it does not increase food-related anxiety, interfere with other interventions for DGBIs, or reduce diet quality. It is helpful to set the expectation that the gluten-free diet is a time-limited trial. If the patient and family deem the diet to be beneficial and decide to continue with it, a dietitian should be consulted to ensure the nutritional adequacy of the restricted diet.
•FODMAPs – 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 [88]. There is insufficient evidence to support routine use of a low-FODMAP diet for the management of children with DGBIs [93]. However, it is reasonable to do a trial of this intervention in those with symptoms suggesting abnormal absorption of carbohydrates, such as diarrhea and excessive gas formation.
Information on the role of FODMAPs in triggering symptoms in children with DGBIs is limited [18]. Several studies in this population reported improvement in pain with fructose restriction, but these studies did not include a control group [94-96]. In a randomized crossover trial of 48 hours of a low- versus high-FODMAP diet in 33 children (7 to 17 years) with irritable bowel syndrome (IBS), a low-FODMAP diet was associated with some improvement in gastrointestinal symptoms (eg, bloating, nausea) and decreased breath hydrogen production [97,98]. Mean pain severity scores decreased on both diets compared with baseline. Indirect evidence to support this approach comes from studies in adults with IBS. (See "Treatment of irritable bowel syndrome in adults".)
If the decision is made to trial a low-FODMAP diet, it should be implemented in consultation with a dietitian to promote adherence, ensure nutritional adequacy [78], monitor for disordered eating patterns, and plan for reintroduction of foods to assess for tolerance to keep the diet as minimally restrictive as possible [99]. 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) [100]. 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 overrestriction and/or improve adherence [93].
Anxiety — Identification of coexisting anxiety in patients with DGBIs is critical. Anxiety disorders are estimated to affect 40 to 85 percent of pediatric patients with DGBIs [101,102]. It is important to explain to the patient and caregivers that screening for anxiety does not imply that the abdominal pain is a manifestation of a psychological disorder but rather that anxiety and the abdominal pain may coexist due to shared causative factors or as a consequence of coping with chronic pain [40]. In addition, there is evidence that anxiety may exacerbate functional impairment in children and adolescents with DGBIs [20].
Several nonpharmacologic therapies can be used to try to mitigate the physiologic effects of anxiety, including abdominal pain [24]. (See 'Interventions to improve coping' above.)
Nonpharmacologic therapies can be helpful, and the related follow-up visits also provide the opportunity for the clinician, caregivers, and patient to assess for 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 (eg, 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".)
Other — Other comorbidities, such as sleep disturbances and restrictive eating disorders, have also been more commonly reported in patients presenting with DGBIs. These comorbid conditions should be screened for and may represent potential therapeutic targets as well [103,104]. (See "Eating disorders: Overview of epidemiology, clinical features, and diagnosis", section on 'Screening'.)
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 disorders of gut-brain interaction (DGBIs; also known as functional abdominal pain disorders) 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 dysbiotic microbiota, by enhancing the intestine's mucosal barrier, or by altering the intestinal inflammatory response [105].
The most effective probiotic strain, dose, or treatment duration has not been established [106,107]. Given that probiotics generally are safe [108], 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) [109]. 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 a DGBI 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 [107]. 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 a DGBI that includes constipation or irregular 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 [110]. 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 DGBIs concluded that water-soluble fibers, particularly psyllium, may provide a slight benefit [111].
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 DGBIs [18,112,113]. (See 'General management strategies' above.)
Although the evidence is limited, peppermint oil is thought to decrease muscle spasms in the gastrointestinal tract by acting directly on smooth muscle [24] or indirectly through blockade of receptors on the smooth muscle nerves [114]. A 2022 systematic review of pharmacologic treatments for DGBIs 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) [115-117]. 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) [112].
Peppermint oil capsules are available commercially. In both of the trials described above, peppermint oil was administered as a pH-dependent, enteric-coated capsule (187 mg three times per day for children weighing <45 kg and 374 mg three times per day for children weighing >45 kg) [117,118]. Excessive intake of peppermint oil may lead to exacerbation of gastroesophageal reflux and has been associated with interstitial nephritis and acute kidney failure [118,119].
●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 [120], few studies have evaluated the effectiveness of antispasmodics in the treatment of childhood DGBIs [60,115]. A 2022 systematic review of pharmacologic treatments for DGBIs 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 [115,121-123]. Three of 44 participants discontinued mebeverine for adverse effects (drowsiness, nervousness, nausea), and 1 of 30 participants discontinued drotaverine due to urticaria [115].
The long-term use of other antispasmodic medications in children may be limited by anticholinergic side effects (eg, dry mouth, blurred vision) [24]. Additional studies of safety and efficacy are necessary before antispasmodic medications can be routinely recommended for children with DGBIs.
●Other interventions
•Antidepressants – We do not suggest routinely prescribing antidepressants for children and adolescents with DGBIs 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 DGBIs 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 DGBIs are limited and it is uncertain whether antidepressants are beneficial in the treatment of DGBIs in children [124].
•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 (especially for young children) 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 DGBIs and dyspeptic symptoms in children [125,126]. In a randomized trial of 29 children and adolescents with DGBIs, 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 [127]. These results need to be confirmed with larger, additional trials before cyproheptadine can be routinely recommended for the treatment of DGBIs [22].
•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 [128]. In a randomized sham-controlled trial in 115 adolescents with DGBIs, auricular neurostimulation reduced abdominal pain severity, frequency, and duration with no serious adverse effects [129]. In another randomized sham-controlled trial in 50 adolescents with IBS, auricular neurostimulation reduced abdominal pain scores and improved overall well-being [128]. 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 [130].
Although these findings are promising, and the US Food and Drug Administration has granted permission to market the device for relief of IBS in 11- to 18-year-old adolescents, 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 DGBIs [18,129,131,132].
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 [10]. The pain or discomfort may be exacerbated by eating. Dyspepsia is the predominant symptom in children with functional dyspepsia (table 1).
For children with functional dyspepsia, initial management strategies include [12]:
●Small, frequent meals
●Avoidance of foods, beverages, and medications that exacerbate symptoms (eg, high-fat foods, caffeinated beverages, nonsteroidal antiinflammatory drugs) [80,133] (see 'Dietary triggers' above)
We suggest not routinely using pharmacologic therapy (eg, histamine-2 [H2] blockers, proton pump inhibitors) for children and adolescents with functional dyspepsia. A 2022 systematic review of pharmacologic therapy for DGBIs in children included only one randomized trial with inconclusive results [115,134]. However, for children and adolescents with severe symptoms unresponsive to nonpharmacologic therapies, especially those with symptoms suggesting gastroesophageal reflux disease (eg, frequent heartburn), a four- to six-week trial of acid suppression may be warranted, using either an H2 blocker (cimetidine, famotidine, or nizatidine) or a proton pump inhibitor (lansoprazole or esomeprazole) [12,135,136]. The medication should be discontinued if there is no improvement. (See "Gastroesophageal reflux disease in children and adolescents: Management", section on 'Pharmacotherapy'.)
We suggest not using prokinetic agents (eg, metoclopramide, domperidone, erythromycin) in the treatment of children and adolescents with DGBIs. There is little evidence of efficacy and potential for adverse effects, particularly with metoclopramide and domperidone [12,24,137].
Diarrhea — In some children with IBS, diarrhea is the predominant symptom (table 1). Children and adolescents with ≥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 whose symptoms include diarrhea be allowed to use the bathroom whenever necessary [12,16]. In addition, it is important for the patient to maintain adequate fluid intake.
We suggest not routinely restricting the diet of children with DGBIs and diarrhea. However, on an individual 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 [12]. (See 'Dietary triggers' above.)
We suggest not routinely using antimotility agents for children or adolescents with a DGBI and diarrhea. The diarrhea associated with DGBIs is typically mild and 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 a DGBI. Evaluation and treatment of constipation in children are discussed separately. (See "Constipation in infants and children: Evaluation" and "Chronic functional constipation and fecal incontinence in infants, children, and adolescents: Treatment".)
Unproven interventions
●Open-label placebo – In placebo-controlled trials in children with DGBIs, the response to placebo is substantial [23], which may be related to the natural history of improvement over time, regression to the mean, methodologic factors, and contextual factors (eg, expectations, conditioning) [18]. 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 [138,139]. In a subsequent crossover trial in which 30 children and adolescents with DGBIs 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 [140]. These results suggest that open-label placebo may reduce pain in children with DGBIs, 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 DGBIs but lack clear evidence of benefit in randomized trials. These include rifaximin [141,142], linaclotide, lubiprostone, otilonium bromide (available outside of the United States), fennel, licorice, ginger, and Iberogast (an herbal therapy) [143]. (See "Treatment of irritable bowel syndrome in adults".)
FOLLOW-UP —
Children and adolescents with a disorder of gut-brain interaction (DGBI; also known as functional abdominal pain disorders) 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 2) [15,16,43].
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 [27]. (See 'Indications for referral' below.)
Children who develop alarm findings (table 2) require evaluation for an 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 2) 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 [14,16,27,84].
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 —
Disorders of gut-brain interaction (DGBIs; also known as functional abdominal pain disorders) resolve in the majority of children [20,21,144]. 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) [21]. In a prospective study of 132 children with DGBIs 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 [20].
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 time of presentation, and high levels of symptoms at presentation that are followed by rapid improvement [20,35].
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 time of diagnosis, more than six months' duration of pain before seeking treatment, negative life events, and more severe symptoms of anxiety and depression [20,24,145,146].
Some longitudinal studies suggest that children with functional abdominal pain-not otherwise specified (FAP-NOS) go on to have irritable bowel syndrome (IBS) as adults [147-149]. 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) [149]. IBS and functional dyspepsia were the most frequent functional gastrointestinal disorders. After controlling for age, sex, and severity of abdominal pain at 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 [38,150-152]. In a prospective study in which 322 children with DGBIs 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) [38].
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 e-mail 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 – Disorders of gut-brain interaction (DGBIs; also known as functional abdominal pain disorders) can be diagnosed in children who have all of the following:
•Chronic (≥2 months) abdominal pain
•No alarm findings (table 2)
•Normal physical examination
•Stool sample negative for occult blood (if performed; not required for diagnosis)
Several of these disorders have recognizable patterns of symptoms, including irritable bowel syndrome (IBS), functional dyspepsia, and abdominal migraine (table 1). (See 'Terminology' above.)
●Management approach – The goal of management of DGBIs in children and adolescents is return to normal function rather than complete elimination of pain (a rehabilitation approach). Management is individualized according to the child's and family's behavior, triggers, and symptoms. Most cases can be managed in the primary care setting. (See 'Management approach' above.)
●General management strategies
•DGBIs 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 healthy (adaptive) behaviors and avoiding reinforcement of illness (pain-related or maladaptive) behaviors. (See 'Behavior modification' above.)
•For most children and adolescents with DGBIs, we suggest supportive or psychological interventions (eg, relaxation techniques, distraction, guided imagery, self-hypnosis, cognitive behavioral therapy [CBT] (table 3)) rather than no intervention (Grade 2C). These interventions may improve coping and decrease stress/anxiety. (See 'Interventions to improve coping' above.)
●Dietary triggers – It is not necessary to routinely restrict the diet of children and adolescents with DGBIs. However, on a case-by-case basis, a time-limited trial of avoidance of specific dietary triggers (eg, lactose, sorbitol) may be warranted. A gluten-free diet is unlikely to be beneficial for most patients but can be utilized in selected patients with history of symptoms to gluten ingestion, after appropriate counseling and screening to exclude celiac disease. (See 'Dietary triggers' above.)
●Management of symptoms
•In addition to the behavioral interventions described above, we suggest time-limited trials of probiotic therapy, water-soluble fiber (eg, psyllium/ispaghula husk), or peppermint oil (Grade 2C). 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.)
•For children with functional dyspepsia, initial management strategies include small, frequent meals and avoidance of foods, beverages, and medications that aggravate symptoms. If symptoms persist or are severe, it is reasonable to do a time-limited trial of acid-suppressing medication (eg, histamine-2 [H2] blocker, proton pump inhibitor), similar to the approach for children with heartburn and suspected gastroesophageal reflux disease. (See 'Dyspepsia' above and "Gastroesophageal reflux disease in children and adolescents: Management", section on 'Heartburn'.)
•For children with functional abdominal pain and diarrhea, we suggest not routinely using antimotility agents (Grade 2C). If there seems to be a correlation of diarrhea with a specific food trigger (eg, lactose, sorbitol), a time-limited trial of elimination of that food may be warranted. Those with ≥3 loose or watery stools per day for more than two weeks (which is an alarm symptom) require evaluation for organic disease. (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 2) 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 – With appropriate support and management, DGBIs resolve over several months in the majority of children. (See 'Prognosis' above.)
ACKNOWLEDGMENT —
The UpToDate editorial staff acknowledges Mariam R Chacko, MD, who contributed to earlier versions of this topic review.
