Functional gastrointestinal disorders in the first 4 years of life: The new Rome IV criteria

Functional gastrointestinal disorders in the first 4 years of life: The new Rome IV criteria 1Paediatric functional gastrointestinal disorders (FGIDs), such as cyclic vomiting syndrome, functional regurgitation, functional diarrhoea, colic and functional constipation affect up to 20% of children.1−5 However, diagnosing paediatric gastrointestinal disorders is challenging as the accurate diagnosis of many FGIDs relies on the ability of the child to describe their symptoms. Therefore, many FGIDs, such as functional nausea, often cannot be accurately diagnosed until the child is ≥6 years of age.

In 2016, the Rome criteria for FGIDs in paediatric care were refined to assist physicians in diagnosing these disorders. One of the most notable changes was redefining of FGIDs as “disorders of the gut-brain interaction” to reduce the overuse of the word “functional” when referring to non-organic conditions. The other major changes in the Rome IV diagnostic criteria include:

  • A section added on neurobiology
  • A section discussing new questionnaires for assessing pain
  • A section discussing the challenges of diagnosing feeding disorders

Changes to the criteria for functional constipation

Functional constipation was defined in the Rome III criteria as two of the following in infants and toddlers ≤4 years of age occurring for at least 1 month:

  1. Two or fewer defecations per week
  2. History of excessive stool retention
  3. History of painful or hard bowel movements
  4. History of large diameter stools, which may obstruct the toilet
  5. Presence of a large faecal mass in the rectum

In toilet-trained children, the following may also apply:

  1. At least one episode/week of incontinence after the acquisition of toileting skills

However, as an infant passing a stool that would obstruct the toilet is extremely rare, this criterion was removed from the definition in Rome IV and amended to only be used as one of the criteria for toilet-trained children. This updated definition does not change clinical practice.

Differentiating infant regurgitation from gastroesophageal reflux disease (GERD)

The North American Society for Paediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) and European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) guidelines use “bothersome symptoms” as the major criterion to distinguish regurgitation from GERD.7 However, there are no available quantitative methods to define “bothersome” because infants are unable to self-report their symptoms. Consequently, variations in clinical interpretation has resulted in many infants being unnecessarily treated for GERD.

Accordingly, the updated Rome IV classification has removed the use of the word “bothersome” in the definition for GERD. Therefore, the recommended algorithm for care of an infant who presents with regurgitation is to observe the symptoms and relate them to other possible organic causes, such as allergy or asthma. In the majority of children, changing the feeding regimen or food type is sufficient. However, if regurgitation persists, other diseases, such as GERD, can then be considered.

Challenges for developing Rome V

Currently, there are limited studies available on feeding disorders. Understanding of the development and presentation of feeding disorders are based on reports from a psychiatrist. Therefore, for definitions and algorithms of care to be developed, further studies are required.

Additionally, the majority of the data supporting the Rome IV criteria are from studies performed outside of South East Asia. Therefore, while this data provides a good foundation for managing FGIDs, further studies are required to validate these findings in South East Asian populations.


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