Under the recently updated Rome IV criteria, one in four children has a functional gastrointestinal disorder, with significant increases in constipation from the previous iteration of the guidelines.

The prevalence of functional GI disorders (FGIDs) was 25% within the infant/toddler age group and 24% among older children in a representative community sample from the United States. The results were presented at the 2017 Digestive Disease Week (abstracts Su2078 and Su2079).

“These are the first community studies to show prevalence rates for the Rome IV child and adolescent FGIDs and infant and toddler FGIDs,” said Russell Zwiener, MD, a third-year fellow at Louisiana State University Health Sciences Center, in New Orleans, who helped conduct the multicenter collaboration.

The diagnosis of FGIDs is based on symptoms, the criteria for which were updated by members of the Rome Foundation. The Rome IV Pediatric Diagnostic Questionnaire (RIV-PDQ) reflects these changes, and was used in the new study to determine whether the prevalence of FGIDs differed between the Rome IV and III criteria (J Pediatr 2016;179:139-143).

Using an online survey, Dr. Zwiener and his team queried 296 mothers of children aged 1 to 47 months (mean age, 20 months) and 1,075 mothers of older children (mean age, 10.6 years). Three-fourths of the children were white. Mothers completed the RIV-PDQ for their children. Mothers of infants or toddlers also completed the adult Rome IV diagnostic questionnaire for themselves, and were assessed for quality of life using the PedsQL 4.0 Generic Core Scale.

Rome IV FGIDs for infants and toddlers include infant regurgitation, infant colic, infant dyschezia, infant rumination syndrome, cyclic vomiting syndrome, functional diarrhea and functional constipation.

Results from the survey showed that, based on the Rome IV criteria:

• 25% of infants and toddlers combined met the criteria for at least one FGID;
• 38% of infants and 21% of toddlers met the criteria for at least one FGID; and
• 19% of infants and toddlers met the criteria for more than one FGID.

The incidence of regurgitation and colic was the same for the Rome IV criteria as for Rome III (25% and 5%, respectively).

Regurgitation was reported by about 25% and colic by 5% of the mothers surveyed for both the Rome IV and III criteria. The researchers observed no differences in sex or race with regard to frequency or type of FGID.

Infants had a higher prevalence of functional constipation (12% vs. 4%) and less functional diarrhea (0% vs. 3%) with the Rome IV criteria compared with Rome III. These differences were similar for toddlers (18% vs. 9% and 0% vs. 6%, respectively).

“We saw a tripling in functional constipation in infants (ages 0-12 months) and a doubling in toddlers (ages 13-47 months),” Dr. Zwiener noted. “I don’t know if I believe the increase is that much, but I do think it’s closer to what we do see in practice.”

Dr. Zwiener said the prevalence of functional diarrhea may not be reliable, due to a small sample size.

Not surprisingly, he said, children with FGIDs had more medical visits related to GI problems (P<0.001) and more hospitalizations (P<0.01) than those without the conditions, and mothers missed more work due to their children’s illness (P=0.007). FGIDs were associated with reduced quality of life for both children and mothers, Dr. Zwiener reported.

Some “parent–child overlap” was observed: Mothers reporting an FGID were more likely to have a child with an FGID, and those with hard stools were more likely to have an infant or toddler with hard stools (P=0.001).

FGIDs in Children and Adolescents

In the older age group, FGIDs included functional nausea and vomiting (cyclic vomiting syndrome, functional nausea and vomiting, rumination syndrome, aerophagia), functional abdominal pain disorders (functional dyspepsia and abdominal pain not otherwise specified), abdominal migraine, irritable bowel syndrome and functional defecation disorders (functional constipation, nonretentive fecal incontinence).

The survey revealed that 24% of children qualified for at least one FGID, and of those, 36% had two or more disorders. The most common were functional abdominal pain disorders (17%) and functional defecation disorders (14%). The overall prevalence of FGIDs was similar for Rome III and IV diagnoses, except that functional dyspepsia increased from 0.2% to 7.9% and abdominal migraine fell from 9% to 1% under the Rome IV criteria, Dr. Zwiener reported.

For the first time, the Rome IV criteria also subtyped functional dyspepsia into postprandial distress syndrome (FD-PDS) and epigastric pain syndrome.

“Approximately 95% of children within this category had FD-PDS, which is more reflected by bloating than pain,” Dr. Zwiener said. “Rome III did not include nonpainful symptoms such as bloating, and this is now in the questionnaire.”

The reduction in abdominal migraine probably reflects adjustments in diagnostic criteria and wording of the questionnaire. “And we think its prevalence in Rome III was artificially high,” he added. As for the absence of rumination syndrome, the researchers believe parents lack awareness and understanding of this symptom. “We definitely see it in practice,” he said.

Revisions ‘Have Enhanced Diagnostic Specificity’

Julie Khlevner, MD, director of the Pediatric Gastrointestinal Motility Center at NewYork-Presbyterian/Columbia University Medical Center, in New York City, estimated that about one-third of her patients have symptoms consistent with FGIDs.

“FGIDs are common in children of all ages, and have a significant impact on families, the patient’s quality of life, and health care utilization and related costs,” Dr. Khlevner said. “It is therefore imperative to recognize these disorders, allow patients and families to embrace the problem, prevent unnecessary investigations, ultimately improve patient care, and limit health care costs. Future revision to the Rome criteria will likely result in the proposal of new entities, further enhancing our understanding of FGIDs leading to improved therapeutic strategies.”

—Caroline Helwick

Drs. Khlevner and Zwiener reported no relevant financial conflicts of interest.