List of Abbreviations
Antibiotics – systemic antibacterial drugs
Du – duodenum
GI – gastrointestinal tract
PPI – proton pump inhibitors
NSAIDs – Non-steroidal anti-inflammatory and antirheumatic drugs
PCR – polymerase chain reaction
RC – Rome criteria
CRP – C-reactive protein
FD – functional dyspepsia
FGID – functional gastrointestinal disorders
EGD – esophagogastroduodenoscopy
H. pylori – Helicobacter pylori
Terms and Definitions
Functional dyspepsia (FD) is a symptom complex including pain, burning, and a feeling of fullness in the epigastric region after eating, and early satiety, which occur at least once a week for at least 2 consecutive months, and which cannot be explained by organic diseases (peptic ulcer disease, tumors, etc.).
Rome criteria (RC) are international evidence-based guidelines for the diagnosis and treatment of functional gastrointestinal disorders.
Helicobacter pylori (H. pylori) is a motile, spiral or S-shaped, gram-negative, microaerophilic bacterium capable of colonizing the gastric mucosa and, in some cases, the duodenal mucosa, causing inflammation.
Eradication therapy is a comprehensive treatment aimed at eliminating Helicobacter pylori (H. pylori) infection.
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
Functional dyspepsia (ICD-10 K30; Rome IV H2a) is a symptom complex related to the gastroduodenal region (epigastric and/or periumbilical pain, postprandial fullness, nausea, early satiation) in the absence of any organic, systemic, or metabolic diseases that could explain these manifestations [1].
In the latest Rome IV criteria (2016), the term "bothersome" was added to each of these symptoms [2].
Only the frequency, periodicity, and duration of symptoms allow the diagnosis of FGID, specifically FD [1, 3].
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
Modern concepts regarding the nature of functional GI disorders can generally be represented by the so-called "biopsychosocial model," which integrates pathophysiological mechanisms and psychosocial factors.
Factors that disrupt motility and regulation within the "brain-gut" axis, cause visceral hypersensitivity and impaired mucosal homeostasis, as well as genetic predisposition, play a role in the development of FD and other forms of FGID manifesting as abdominal pain [1, 4, 5, 6, 7, 8].
Etiological factors of FD include social maladjustment, psychological stress, fatigue, and disrupted sleep, study, and rest schedules [6, 8].
Factors disrupting mucosal homeostasis include the use of medications (anti-inflammatory or antibacterial drugs), food allergies, and H. pylori infection [2, 8, 9].
About 20% of FD cases develop as a consequence of acute intestinal infections and foodborne toxicoinfections [8, 10].
Disruptions in gastroduodenal motility contribute to the genesis of FD symptoms: gastroesophageal and duodenogastric refluxes, impaired gastric accommodation, and delayed gastric and duodenal emptying.
Minimal activity inflammation of the gastric and/or duodenal mucosa is possible in FD and does not contradict this diagnosis. A complex of mechanisms leads to visceral hypersensitivity of the gastric and duodenal walls, which results in the onset and persistence of symptoms under the influence of any stimuli [6, 7].
FD may act as a gastroenterological "mask" of autonomic dysfunction syndrome, either alone or in combination with manifestations from other parts of the digestive system or other body systems.
One possible mechanism of FD is impaired secretion of the humoral digestive regulator ghrelin—a peptide synthesized by enteroendocrine cells that activates gastric and duodenal motility, gastric secretion, and induces hunger by stimulating appetite through a direct effect on the central nervous system [11]. In addition, changes in gastrin and cholecystokinin levels may be important in the development of motor disorders in FD.
H. pylori infection may play a role in the development of dyspeptic symptoms by contributing to altered gastric secretion and increased visceral hypersensitivity. However, there is no evidence that H. pylori causes this disorder [1, 12].
Dietary errors, according to most researchers, play a minor role in the development of FD. However, it has been established that many FD patients avoid certain foods due to a potential increase in the severity of dyspeptic symptoms. Foods that these patients tolerate least well include red hot peppers, onions, mayonnaise, nuts, citrus fruits, chocolate, coffee, and carbonated beverages [6, 10].
1.3 Epidemiology of the Disease or Condition
Data on the prevalence of FD in different countries vary widely due to different diagnostic criteria and interpretations of complaints. FD occurs in 20% of Europeans, 29% in the USA, and 11% in Korea [3, 9].
According to epidemiological studies in the Russian Federation, up to 30–40% of children suffer from various forms of FGID, and 11.8–46% of them have FD [10, 13].
1.4 Features of Coding the Disease or Condition
K30 – Functional dyspepsia
1.5 Classification of the disease or condition
To make the diagnosis more objective, it is advisable to determine the FD subtype based on the predominant symptoms. There are 2 main variants of FD [1]:
Postprandial distress syndrome (postprandial distress syndrome), which includes postprandial fullness or early satiation that occurs earlier than the usual end of a meal. Additional symptoms considered include upper abdominal bloating, postprandial nausea, or excessive belching.
Epigastric pain syndrome, which includes pain (severe enough to interfere with daily activities). The pain is localized in the epigastrium or periumbilical region, does not radiate to other areas (retrosternal, flank, or lower abdomen), and is not relieved by defecation or flatus.
Mixed FD is distinguished as a separate category.
1.6 Clinical presentation of the disease or condition
The clinical picture includes pain in the epigastric and/or periumbilical region combined with 1 or more symptoms:
- postprandial fullness,
- nausea,
- early satiation.
An important aspect is the frequency of these complaints—at least once a week for no less than 2 consecutive months, with clinical signs manifesting with sufficient intensity to cause distress to the child [14, 15].
Differential diagnosis
Differential diagnosis should be performed with organic diseases presenting with dyspepsia syndrome (peptic ulcer disease, gastroesophageal reflux disease, NSAID-associated gastropathy/duodenopathy, gastric cancer), as well as with other functional gastrointestinal disorders accompanied by abdominal pain (functional abdominal pain, irritable bowel syndrome, biliary dysfunction). A pathognomonic sign for FD is the association of epigastric pain and discomfort with meals. In individual clinical cases, it may be necessary to rule out food allergies, including non-IgE-mediated allergies, and eosinophilic esophagitis [16, 17].
In preschool and early school-age children, due to the non-specific nature of the pain syndrome, the differential diagnosis also includes diseases of the urinary system, liver, and pancreas.
2. Diagnostics, medical indications and contraindications for diagnostic methods
Criteria for establishing the diagnosis/condition:
FD is a clinical andamnestic diagnosis. The clinical signs listed above must manifest with sufficient intensity to impact the patient's daily activities, i.e., to be "bothersome" [1, 3].
After a complete workup, it must be confirmed that the symptoms cannot be explained by other pathological conditions [1].
2.1 Complaints and Anamnesis
Potential complaints in patients with FD and their interpretation are presented in subsection 1.6.
Recommended to check all patients with clinical signs of FD for the presence or absence of "alarm" symptoms; the presence of at least one of the following "alarm" symptoms in children warrants a more thorough diagnostic workup:
Family history of IBD, celiac disease, or peptic ulcer disease;
Dysphagia, odynophagia;
Recurrent vomiting;
Signs of gastrointestinal bleeding;
Arthritis;
Unexplained weight loss;
Linear growth deceleration;
Delayed puberty;
Unexplained fever [1];
Signs of inflammation in the blood (leukocytosis, elevated ESR) [6, 69].
The presence of "alarm" symptoms may indicate organic diseases (Appendix A3.1).
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comment: failure of standard therapy for a "functional disorder" within 2 weeks should also be considered an "alarm" symptom.
2.2 Physical Examination
Recommended that children with clinical signs of FD undergo a physical examination: assessment of the child's physical development, superficial and deep abdominal palpation (palpation for esophageal, gastric, and duodenal diseases), which may reveal tenderness in the epigastric and/or periumbilical region; assessment of peritoneal irritation signs, which is important in cases of pronounced abdominal pain; liver percussion (percussion for liver and biliary tract diseases) to rule out concomitant hepatomegaly; auscultation (auscultation for esophageal, gastric, and duodenal diseases) to assess gastrointestinal peristalsis; and evaluation of the skin to detect cutaneous signs of allergy [13, 69].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: during physical examination, there are no pathognomonic findings for FD [31]. It is performed as part of the initial and follow-up visit (examination, consultation) of a pediatrician/initial and follow-up visit (examination, consultation) of a district pediatrician/ initial and follow-up visit (examination, consultation) of a general practitioner (family physician) and/or initial and follow-up visit (examination, consultation) of a gastroenterologist.
2.3 Laboratory Diagnostics
There are no laboratory markers pathognomonic for functional dyspepsia. Laboratory tests are performed in children to exclude/confirm organic pathology, as well as for cancer prevention in older adolescents.
Patients with features characteristic of FD are recommended to undergo a complete blood count (with determination of total hemoglobin, hematocrit evaluation, red blood cell count, color index, platelet count, white blood cell count, and differential leukocyte count) to confirm/exclude "alarm" symptoms—anemia due to bleeding from erosive and ulcerative lesions of the gastroduodenal mucosa and inflammatory changes [15, 18, 19, 20, 21, 69].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: leukocytosis may indicate an infectious etiology of the disease, microcytic anemia indicates occult blood loss or impaired iron absorption, macrocytic anemia develops due to vitamin B12 deficiency in autoimmune gastritis [15, 18, 19, 20, 21]. The test is performed at the initial diagnosis and in the presence of clinical "alarm" symptoms.
If anemia is detected, diagnosis and treatment are carried out in accordance with the relevant clinical guidelines.
Patients with signs of FD are recommended to undergo a urinalysis for differential diagnosis with urinary system diseases [22].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: abdominal pain in children may indicate kidney or urinary tract pathology. If urinalysis abnormalities are detected, further nephrological evaluation is required.
Patients with FD who have anemia/iron deficiency are recommended to selectively undergo a fecal occult blood test to diagnose occult bleeding and select an endoscopic examination in case of a positive result [23, 24].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: when evaluating the results of the fecal occult blood test, it must be borne in mind that a positive reaction can occur in many other diseases, use of certain medications (bismuth tripotassium dicitrate**, iron supplements, ascorbic acid**), or failure to follow dietary recommendations prior to the test (eating meat, teething, etc.).
The test generally can be used when EGDS is not feasible and/or when searching for sources of occult bleeding in the lower gastrointestinal tract.
Preference should be given to the immunochemical fecal occult blood test to avoid false-positive results.
Patients with signs of FD whose symptoms persist despite ongoing therapy are recommended to undergo a "second-line" workup, including a general clinical blood chemistry panel (C-reactive protein, serum iron, and serum ferritin) [24, 31, 70, 71, 72].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: elevated CRP and ferritin indicate the presence of organic diseases and require further investigation. Decreased serum iron and ferritin indicate anemia; further diagnosis and treatment are carried out in accordance with the relevant clinical guidelines.
For patients with signs of FD whose symptoms persist despite ongoing therapy, a "second-line" workup is recommended, including microscopic stool analysis for giardiasis cysts (Microscopic examination of stool for protozoa / Microscopic examination of stool for protozoa using concentration methods) or PCR testing (Determination of Giardia lamblia antigens in stool samples / Molecular biological examination of feces for Giardia lamblia / Determination of Giardia lamblia DNA in feces by PCR) [25, 26, 27, 28].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: a positive result will indicate the need for antiparasitic therapy.
Patients with signs of FD whose symptoms persist despite ongoing therapy are recommended to selectively undergo blood testing for anti-tissue transglutaminase antibodies (IgA class) if differential diagnosis with celiac disease is necessary, and fecal calprotectin as an indicator of intestinal inflammation activity to rule out inflammatory bowel disease [22, 29, 30].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
2.4 Instrumental Diagnostics
Patients with signs of FD are recommended to undergo an abdominal ultrasound (comprehensive abdominal ultrasound) [22, 69].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: the study helps assess the condition of the liver, gallbladder, and pancreas.
Patients (adolescent girls) with signs of FD whose symptoms persist despite ongoing treatment are recommended to undergo a "second-line" workup, including pelvic ultrasound for differential diagnosis [69].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: pelvic ultrasound allows assessment of the ovaries and bladder.
Patients with FD in the presence of "alarm" symptoms are recommended to undergo upper gastrointestinal endoscopy (esophagogastroduodenoscopy [EGDS]) for differential diagnosis [31, 32, 69].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: additional criteria for performing EGDS, apart from "alarm" symptoms, may include:
family history of peptic ulcer disease;
clinical features (night pain, hunger pain, rare severe pain, severe pain, heartburn, and acid regurgitation);
presence of iron deficiency.
Using these criteria, indications for EGDS are present in 43% of children with dyspepsia symptoms [33].
When performing EGDS in patients with suspected stomach and duodenal disease, it is recommended to perform a biopsy of the gastric and duodenal mucosa (endoscopic gastric biopsy, endoscopic duodenal biopsy) (from the body and antrum of the stomach, duodenal bulb, and post-bulbar area) followed by examination of the biopsy material (pathological-anatomical examination of gastric biopsy/surgical material, pathological-anatomical examination of duodenal biopsy/surgical material using immunohistochemical methods), microscopic examination of gastric material for H. pylori, and detection of inflammatory changes, atrophy, and metaplasia for differential diagnosis [34, 35, 36, 37, 38, 39, 40, 41, 72].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: pathological-anatomical (histological) examination is indispensable for assessing the inflammatory process in the gastric mucosa, the degree of its activity (active, inactive), and in detecting H. pylori itself [35].
To rule out eosinophilic esophagitis, endoscopic esophageal biopsy and pathological-anatomical examination of esophageal biopsy/surgical material may be required [42, 43].
Unlike in adults, there is no single protocol regarding the number of biopsies in children; targeted biopsy is performed from affected areas of the gastroduodenal mucosa. Biopsies should be taken during any diagnostic endoscopy in children, even from unchanged areas [31, 32]. For diagnosing special forms of gastritis (autoimmune atrophic, atrophic-hyperplastic, hypertrophic, lymphocytic, granulomatous, eosinophilic), the results of pathological-anatomical (histological) examination are decisive.
2.5 Other Procedures
Special attention should be given to the diagnosis of H. pylori infection in childhood because, unlike the adult population, the "test-and-treat" strategy is not used in children, where eradication therapy is prescribed to all patients upon detection of H. pylori, regardless of symptoms. In pediatric practice, a more differentiated approach is important, especially when the microorganism is detected in a patient without symptoms of dyspepsia, where the question of treatment can be considered after thorough discussion with the patient/parents [1, 31, 69, 72].
Patients with signs of functional dyspepsia are selectively recommended to be tested for H. pylori infection (13C urea breath test for Helicobacter Pylori and/or fecal Helicobacter pylori antigen test, or rapid immunochromatographic fecal test for Helicobacter pylori) to determine the need for eradication therapy [10, 14, 41, 72, 73].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: testing children with signs of functional dyspepsia for H. pylori is indicated when H. pylori infection is suspected (family history of peptic ulcer disease, gastric cancer, refractory iron deficiency anemia, idiopathic thrombocytopenic purpura) [31, 32, 73].
In patients with functional dyspepsia, if symptoms persist despite therapy for epigastric pain syndrome, selective diagnostic testing for H. pylori infection is recommended (13C urea breath test for Helicobacter Pylori and/or fecal Helicobacter pylori antigen test, or rapid immunochromatographic fecal test for Helicobacter pylori) [10, 44, 72, 73].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: an increased frequency of fecal H. pylori antigen detection has been noted in patients with functional dyspepsia [45, 74]. At the same time, diagnostic testing for H. pylori in children is justified only when the expected benefit outweighs the costs and risks associated with testing and subsequent treatment [31, 73].
If gastritis, duodenitis, gastric ulcer, or duodenal ulcer is suspected, studies should be performed in accordance with relevant guidelines.
In patients with signs of functional dyspepsia, if symptoms persist despite therapy for epigastric pain syndrome, allergy testing (cutaneous tests for allergen reactivity, blood test for antibodies to plant, animal, and chemical antigens) is selectively recommended for the differential diagnosis of food allergy and eosinophilic esophagitis [16, 17].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: allergy testing is necessary to confirm the allergic nature of manifestations, identify causative allergens in order to develop recommendations on lifestyle and diet, and determine the feasibility of allergen-specific immunotherapy. Allergy testing can be performed by skin testing with non-bacterial allergens (cutaneous tests for allergen reactivity), determination of specific serum IgE levels (blood test for antibodies to plant, animal, and chemical antigens), diagnostic elimination, and trial introduction of the suspected product [46, 47].
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
3.1 Conservative Treatment
3.1.1 Diet Therapy
Patients with functional dyspepsia are recommended to normalize their daily routine and dietary habits for therapeutic purposes [48].
GCR CLoE 3Grade of Recommendation C (Level of Evidence – 3)
Comment: the diet should be complete and balanced, but caffeine-containing, spicy, and fatty foods should be excluded; large meals should be avoided, and dinner should be eaten at least 3 hours before bedtime. More frequent consumption of smaller portions of food may have a positive effect on the manifestations of functional dyspepsia [49]. The main foods whose excessive consumption can exacerbate functional dyspepsia symptoms include fast food, fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) (fruits, soft drinks) [45, 50].
Increased carbohydrate intake may cause symptoms similar to postprandial distress syndrome due to its potential effect on gastric fundus accommodation. In addition, high-glycemic-index foods physiologically increase the release of glucagon-like peptide-1 and cholecystokinin, which in turn can delay gastric emptying and cause a prolonged feeling of fullness.
3.1.2 Pharmacotherapy
Patients with functional dyspepsia are recommended to be prescribed medications for the treatment of functional gastrointestinal disorders (gastrointestinal motility stimulants or drotaverine**) to influence gastrointestinal motility [51, 52, 69].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comment: for feelings of heaviness in the epigastric region and early satiety, gastrointestinal motility stimulants (domperidone) may be used in children over 12 years of age at 10 mg 3 times daily, including before bedtime if necessary; trimebutine may be used in children over 12 years of age at 100–200 mg 3 times daily, children aged 5–12 years: 50 mg 3 times daily, and children aged 3–5 years: 25 mg 3 times daily [53, 54, 55, 56, 69].
For the symptomatic treatment of spastic abdominal pain, the following symptomatic treatment is most commonly prescribed: drotaverine** (40 mg tablets for children from 6 years of age: aged 6 to 12 years: 40 mg per single dose 1–2 times daily. Maximum daily dose is 80 mg (two 40 mg tablets); over 12 years: 40 mg per single dose 1–4 times daily or 80 mg per single dose 1–2 times daily. Maximum daily dose is 160 mg (four 40 mg tablets)) and others.
Patients with functional dyspepsia with epigastric pain syndrome are recommended to receive acid-neutralizing therapy (antacids) [1, 2, 53, 54, 55, 56, 80].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comment: antacids are prescribed to patients with functional dyspepsia for a short period to reduce peripheral hypersensitivity through acid-neutralizing and mucocytoprotective properties. The drugs are prescribed in accordance with the official instructions. For example, a drug from the «Antacids» group — algedrate + magnesium hydroxide for children aged 10 to 15 years: 5 ml 3–4 times daily or 10 ml 1–2 times daily, or 1 sachet 1–2 times daily; from 15 years of age orally 15 ml, 1–2 hours after meals and at bedtime or as needed (no more than 6 tablespoons per day).
However, the efficacy of antacid monotherapy in adults has not been proven; in a number of studies, it does not differ from the placebo effect [75, 76], and the evidence base in children is small [77].
Patients with functional dyspepsia and epigastric pain syndrome combined with GERD are recommended to selectively receive proton pump inhibitors (PPIs) [57, 58, 72].
GRC BLEL 2Grade of Recommendation B (Level of Evidence – 2)
Comment: the positive effect of PPIs in the treatment of functional dyspepsia, mainly for epigastric pain syndrome, has a high level of evidence. They are prescribed in accordance with the clinical guidelines for GERD [72].
Patients with refractory functional dyspepsia are recommended an initial examination (consultation) by a pediatric psychiatrist / initial examination by a psychiatrist, addressing the need to prescribe drugs from the "Hypnotics and sedatives" or "Antidepressants" groups as an option for etiological treatment of functional dyspepsia: relief of psychological stress, anxiety, fatigue, sleep disturbances, and school difficulties [1, 59, 69].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: used as prescribed by a psychiatrist [57, 60].
Herbal sedatives based on valerian (Valeriana officinalis rhizomes with roots extract) and motherwort (Leonurus cardiaca tincture, Leonurus cardiaca extract, Leonurus cardiaca herb) are safer [61]. These drugs are prescribed in accordance with the instructions for children starting from 12 years of age.
3.1.3 H. pylori eradication
Patients with functional dyspepsia with epigastric pain syndrome who are refractory to standard therapy and test positive for H. pylori may be recommended eradication therapy [31, 61, 69].
GCR CLEL 5Grade of Recommendation C (Level of Evidence – 5)
Comments: the rationale for eradication therapy to relieve dyspeptic symptoms is questionable; at the same time, in some patients, it contributes to the sustained elimination of symptoms [2, 21].
Eradication therapy is carried out in accordance with the clinical guidelines "Gastric and/or duodenal ulcer" [79].
3.2 Surgical Treatment
Not required.
3.3 Other Treatment
It is recommended to reassure the family in the absence of signs of serious pathology in a child with functional dyspepsia and advise parents to avoid reinforcing symptoms through "secondary gains," such as missing school or being excused from normal activities due to pain, and to return to a normal daily routine whenever possible [62].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: if "red flag" symptoms appear, support should be provided and the condition reassessed (see the "Diagnostics" section).
When psychological factors exacerbating the symptoms of functional dyspepsia are suspected, a patient with functional dyspepsia is recommended an initial/follow-up examination (testing, consultation) by a medical psychologist and/or an initial/follow-up examination (consultation) by a neurologist for the purpose of identification, correction, and therapeutic interventions [30].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: factors exacerbating functional dyspepsia symptoms include: bullying; chronic stress or anxiety; sexual, emotional, or physical abuse; domestic violence, etc.
It is not recommended to routinely use antidiarrheal microorganisms (probiotics or synbiotics) in patients with functional dyspepsia presenting with abdominal pain due to insufficient evidence base [63].
GGR BLOE 1Grade of Recommendation B (Level of Evidence – 1)
Comment: the results of some meta-analyses indicate that antidiarrheal microorganisms (probiotics and synbiotics) may be more effective than placebo in achieving treatment success in functional dyspepsia, but the evidence is of low certainty and demonstrates little to no difference between antidiarrheal microorganisms (probiotics or synbiotics) and placebo in complete pain relief.
It is recommended to selectively prescribe physical therapy methods for children with functional dyspepsia: drinking hydrocarbonate-chloride sodium-calcium waters of low and medium mineralization (mineral water treatment for diseases of the esophagus, stomach, duodenum/mineral water intake); interference therapy (exposure to interferential currents), electrosleep, galvanization of the collar zone according to Shcherbak (galvanization for diseases of the peripheral nervous system), amplipulse therapy (exposure to sinusoidal modulated currents) as an adjunct to pharmacotherapy to normalize gastrointestinal motility [45].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comments: there is insufficient high-quality evidence regarding the efficacy of the listed methods.
4. Medical Rehabilitation and Sanatorium-Resort Treatment
For rehabilitation purposes, it is recommended that patients with functional dyspepsia be selectively prescribed spa and resort treatment after the resolution of the acute disease phase and eradication therapy in case of *H. pylori* infection, typically 3–6 months after the initiation of treatment [64, 65, 66].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comment: currently, there is no convincing evidence that spa and resort treatment, as well as therapeutic exercise, improves the prognosis or affects the outcomes of functional dyspepsia. High-quality, large-scale studies are needed to draw a definitive conclusion regarding the necessity of this treatment. Therapeutic exercise (physical therapy for diseases of the esophagus, stomach, and duodenum) and medical massage should be considered to improve blood and lymph circulation in the abdominal cavity; normalize gastric and duodenal motility, as well as secretory and neurohumoral regulation of digestive processes; and create favorable conditions for reparative processes in the gastric and duodenal mucosa in the absence of contraindications, along with psychotherapeutic and physiotherapeutic treatments.
5. Prevention and Dispensary Observation
Prevention:
proper nutrition appropriate for the child's age (routine, rhythm, balance);
cessation of bad habits;
normalization of sleep and rest schedule;
regular physical activity [1, 4, 5, 6, 7, 8, 45].
Vaccination
Functional dyspepsia is not a contraindication to vaccination with any type of vaccine [Order of the Russian Ministry of Health No. 1122n dated December 6, 2021 “On Approval of the National Calendar of Preventive Vaccinations and the Calendar of Preventive Vaccinations by Epidemiological Indications and the Procedure for Preventive Vaccinations”, Methodological Guidelines of the Chief State Sanitary Inspector of the Russian Federation “MU 3.3.1.1095-02. 3.3.1. Vaccine Prophylaxis. Medical Contraindications to Preventive Vaccinations with National Immunization Schedule Preparations. Methodological Guidelines”].
Dispensary follow-up (Active surveillance)
Dispenser surveillance (clinical observation) for patients with functional dyspepsia is recommended to be carried out jointly by a district pediatrician / general practitioner (family doctor) and/or a gastroenterologist in an outpatient setting (dispensary appointment (examination, consultation) by a pediatrician / general practitioner (family doctor) and/or initial and follow-up appointment (examination, consultation) by a gastroenterologist and/or dispensary appointment (examination, consultation) by a gastroenterologist), taking into account grouping (I–IV) depending on the acute or remission state of the disease, with the aim of conducting anti-relapse and rehabilitation measures that vary across registration groups [45, 67].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comment: in case of persistent long-term clinical and laboratory remission after 3 years of follow-up, the issue of discharging the patient from dispensary registration may be raised.
6. Organization of Medical Care
The majority of patients with functional dyspepsia are subject to outpatient monitoring and treatment.
Depending on necessity, medical care of any type, under any conditions, and in any form provided for by the legislation of the Russian Federation may be rendered.
Diagnosis and management of patients with functional dyspepsia are carried out by a gastroenterologist and/or a pediatrician / district pediatrician / general practitioner (family doctor).
Indications for hospitalization in a medical organization:
severe abdominal pain syndrome (8–10 points on a ten-point scale);
the need for eradication therapy under medical supervision in case of a high risk of allergic reactions or antibiotic-associated diarrhea;
the need to perform an endoscopic examination with multiple biopsies under anesthesia;
presence of "alarm" symptoms requiring differential diagnostic workup;
social indications (inability to conduct examination/treatment in an outpatient setting).
The organization of therapeutic dietary nutrition for patients with functional dyspepsia during inpatient treatment in medical organizations is carried out in accordance with the Order of the Russian Ministry of Health No. 1008n dated September 23, 2020, “On Approval of the Procedure for Providing Patients with Therapeutic Nutrition” (Appendix 3).
7. Additional Information
Currently, there are no clear data on factors influencing the prognosis or treatment outcome in children with functional dyspepsia. A substantial economic burden of functional dyspepsia on healthcare has been noted. Symptoms of functional dyspepsia persist in the majority of children despite treatment with multiple drugs [68].
Criteria for Evaluating the Quality of Medical Care
№ | Quality criteria | Performance assessment (yes/no) | |
|---|---|---|---|
1. | A complete blood count (CBC) (including total hemoglobin level, hematocrit evaluation, red blood cell count, color index, platelet count, leukocyte count, and differential leukocyte count) has been performed during initial diagnostics in a patient with features characteristic of functional dyspepsia | Yes/no | |
2. | A urinalysis has been performed in a patient with features of functional dyspepsia | Yes/no | |
3. | EGD has been performed in patients with suspected functional dyspepsia and "alarm" symptoms that serve as indications for endoscopic examination during initial diagnostics | Yes/no | |
4. | Testing for H. pylori has been performed if complaints persist in a patient with functional dyspepsia despite prior therapy in case of epigastric pain syndrome, or in the presence of a positive family history of peptic ulcer disease | Yes/no | |
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Appendix A1. Working Group Composition
Alekseeva Anna Alexandrovna – PhD in Medical Sciences, Deputy Head of the Consultative and Diagnostic Center for Children, Pediatrician, Head of the Multidisciplinary Pediatric Day Hospital – Allergist-Immunologist, Leading Research Scientist at the Department of Clinical Immunology and Allergology, Research Institute of Pediatrics and Child Health, Petrovsky National Research Centre of Surgery, Member of the Union of Pediatricians of Russia.
Baranov Alexander Alexandrovich – Academician of the Russian Academy of Sciences, Professor, MD; Honorary President of the Union of Pediatricians of Russia, Advisor to the Head of the Research Institute of Pediatrics and Child Health, Petrovsky National Research Centre of Surgery, Professor at the Department of Pediatrics and Pediatric Rheumatology, Sechenov First Moscow State Medical University of the Russian Ministry of Health (Sechenov University), Chief freelance pediatric specialist of the Russian Ministry of Health.
Baryshnikova Natalia Vladimirovna – Candidate of Medical Sciences, Associate Professor, Senior Research Scientist at the Laboratory of Medical and Social Problems of Pediatrics, Scientific Research Center, St. Petersburg State Pediatric Medical University of the Russian Ministry of Health.
Belmer Sergey Viktorovich – Professor, Doctor of Medical Sciences, Professor at the Department of Hospital Pediatrics No. 2, Pirogov Russian National Research Medical University of the Russian Ministry of Health, Co-Chair of the Society of Pediatric Gastroenterologists, Hepatologists, and Nutritionists, Member of the Union of Pediatricians of Russia.
Bogdanova Natalia Mikhailovna – Candidate of Medical Sciences, Associate Professor at the Department of Propaedeutics of Children's Diseases with a Course in General Child Care, St. Petersburg State Pediatric Medical University of the Russian Ministry of Health, Member of the Society of Pediatric Gastroenterologists, Hepatologists, and Nutritionists, Member of the Union of Pediatricians of Russia.
Vishnyova Elena Alexandrovna – MD, Professor of the Russian Academy of Sciences, Deputy Head of the Research Institute of Pediatrics and Child Health, Petrovsky National Research Centre of Surgery, Professor at the Department of Faculty Pediatrics, Institute of Motherhood and Childhood, Pirogov Russian National Research Medical University (Pirogov University) of the Russian Ministry of Health, Member of the Union of Pediatricians of Russia.
Volynets Galina Vasilyevna – MD, Professor at the Department of Innovative Pediatrics and Pediatric Surgery, Faculty of Additional Professional Education, Associate Professor at the Department of Pediatrics with Infectious Diseases in Children, Faculty of Additional Professional Education, Pirogov Russian National Research Medical University of the Russian Ministry of Health. Head of Department, Department of Gastroenterology, Veltischev Research and Clinical Institute of Pediatrics. Member of the Society of Pediatric Gastroenterologists, Hepatologists, and Nutritionists, Member of the Union of Pediatricians of Russia.
Gundobina Olga Stanislavovna – Candidate of Medical Sciences, Leading Research Scientist, Gastroenterologist at the Research Institute of Pediatrics and Child Health, Petrovsky National Research Centre of Surgery, Member of the Union of Pediatricians of Russia.
Gurova Margarita Mikhailovna – Doctor of Medical Sciences, Leading Research Scientist at the Laboratory of Medical and Social Problems of Pediatrics, Scientific Research Center, St. Petersburg State Pediatric Medical University of the Russian Ministry of Health, Professor at the Department of Propaedeutics of Children's Diseases with a Course in General Patient Care, St. Petersburg State Pediatric Medical University of the Russian Ministry of Health, Member of the Union of Pediatricians of Russia, Member of the Society of Pediatric Gastroenterologists, Hepatologists, and Nutritionists, Deputy Chief Medical Officer for Medical Affairs, St. Petersburg Consultative and Diagnostic Center for Children.
Zavyalova Anna Nikitichna – Doctor of Medical Sciences, Professor at the Department of Propaedeutics of Children's Diseases with a Course in General Patient Care, St. Petersburg State Pediatric Medical University of the Russian Ministry of Health, Member of the Union of Pediatricians of Russia, Member of the Society of Pediatric Gastroenterologists, Hepatologists, and Nutritionists, Member of the Union of Pediatricians of Russia.
Zvyagin Alexander Alekseevich – MD, Professor at the Department of Propaedeutics of Children's Diseases and Polyclinic Pediatrics, Burdenko Voronezh State Medical University of the Russian Ministry of Health, Member of the Society of Pediatric Gastroenterologists, Hepatologists, and Nutritionists.
Kaitukova Elena Vladimirovna – Candidate of Medical Sciences, Deputy Head for Medical Activities – Head of the Consultative and Diagnostic Center for Children, Gastroenterologist, Leading Research Scientist at the Department of Orphan Diseases and Prevention of Disabling Conditions, Research Institute of Pediatrics and Child Health, Petrovsky National Research Centre of Surgery, Associate Professor at the Department of Faculty Pediatrics, Institute of Motherhood and Childhood, Pirogov Russian National Research Medical University (Pirogov University) of the Russian Ministry of Health, Member of the Union of Pediatricians of Russia.
Kalinina Elena Yuryevna – Candidate of Medical Sciences, Head of the Department of Normal Anatomy, St. Petersburg State Pediatric Medical University.
Komarova Elena Vladimirovna – MD, Deputy Head for Expertise of Innovative Treatment and Rehabilitation Methods, Gastroenterologist, Chief Research Scientist at the Department of Orphan Diseases and Prevention of Disabling Conditions, Research Institute of Pediatrics and Child Health, Petrovsky National Research Centre of Surgery, Professor at the Department of Faculty Pediatrics, Institute of Motherhood and Childhood, Pirogov Russian National Research Medical University (Pirogov University) of the Russian Ministry of Health, Member of the Union of Pediatricians of Russia.
Kornienko Elena Alexandrovna – MD, Professor at the Department of Children's Diseases named after Professor I.M. Vorontsov, Faculty of Postgraduate and Additional Professional Education, St. Petersburg State Pediatric Medical University of the Russian Ministry of Health. Chief Freelance Pediatric Gastroenterologist of the Healthcare Committee of the Government of St. Petersburg. Member of the Society of Pediatric Gastroenterologists, Hepatologists, and Nutritionists. Member of the Union of Pediatricians of Russia.
Korolev Grigory Alekseevich – Candidate of Medical Sciences, Endoscopist at the Endoscopic Research Department, National Medical Research Center for Children's Health of the Russian Ministry of Health.
Listopadova Anastasia Pavlovna – Candidate of Medical Sciences, Assistant Professor at the Department of Propaedeutics of Children's Diseases with a Course of General Childcare, Saint Petersburg State Pediatric Medical University, Senior Researcher at the Laboratory of Medical and Social Problems of Pediatrics, Research Center of Saint Petersburg State Pediatric Medical University of the Russian Ministry of Health, Member of the Society of Pediatric Gastroenterologists, Hepatologists and Nutritionists, Member of the Union of Pediatrists of Russia.
Lokhmatov Maksim Mikhailovich – Doctor of Medical Sciences, Endoscopist, Head of the Endoscopic Research Department, Chief Researcher at the Laboratory of Endoscopic, Morphological and Pathological Anatomical Research, National Medical Research Center for Children's Health of the Russian Ministry of Health; Professor at the Department of Pediatric Surgery and Urology-Andrology named after Professor L.P. Alexandrov, I.M. Sechenov First Moscow State Medical University of the Russian Ministry of Health (Sechenov University).
Melnikova Irina Yuryevna – Professor, Doctor of Medical Sciences, Head of the Department of Pediatrics and Pediatric Cardiology, North-Western State Medical University named after I.I. Mechnikov, Member of the Society of Pediatric Gastroenterologists, Hepatologists and Nutritionists, Member of the Union of Pediatrists of Russia.
Namazova-Baranova Leyla Seymurovna – Academician of the RAS, Professor, Doctor of Medical Sciences, President of the Union of Pediatrists of Russia; Past President of EPA/UNEPSA; Head of the Research Institute of Pediatrics and Child Health, Clinical Research Center No. 2 of the Petrovsky National Research Centre of Surgery, Head of the Department of Faculty Pediatrics, Institute of Motherhood and Childhood, Pirogov Russian National Research Medical University of the Russian Ministry of Health (Pirogov University), Chief Freelent Pediatric Specialist in Preventive Medicine of the Russian Ministry of Health.
Novikova Valeria Pavlovna – Doctor of Medical Sciences, Professor, Head of the Department of Propaedeutics of Children's Diseases with a Course of General Childcare, Saint Petersburg State Pediatric Medical University of the Russian Ministry of Health, Head of the Laboratory of Medical and Social Problems of Pediatrics, Research Center of Saint Petersburg State Pediatric Medical University of the Russian Ministry of Health, Member of the Union of Pediatrists of Russia, Member of the Russian Society of Pediatric Gastroenterologists, Hepatologists and Nutritionists.
Pechkurov Dmitry Vladimirovich – Doctor of Medical Sciences, Professor, Head of the Department of Children's Diseases, Samara State Medical University of the Russian Ministry of Health, Member of the Society of Pediatric Gastroenterologists, Hepatologists and Nutritionists, Member of the Union of Pediatrists of Russia.
Potapov Alexander Sergeevich – Doctor of Medical Sciences, Professor, Head of the Center for Inflammatory Bowel Diseases in Children, Head of the Gastroenterology Department, National Medical Research Center for Children's Health of the Russian Ministry of Health; Professor at the Department of Pediatrics and Pediatric Rheumatology, I.M. Sechenov First Moscow State Medical University (Sechenov University), Member of the Union of Pediatrists of Russia.
Revunenkov Grigory Valerievich – Candidate of Medical Sciences, Leading Researcher, Head of the Department of Innovative Diagnostic Research Methods, Ultrasound Diagnostics Physician, Research Institute of Pediatrics and Child Health, Clinical Research Center No. 2 of the Petrovsky National Research Centre of Surgery, Member of the Union of Pediatrists of Russia.
Surkov Andrey Nikolaevich – Doctor of Medical Sciences, Head of the Gastroenterology Department for Children of the Pediatric Hospital, Head of the Department of Scientific Foundations of Pediatric Gastroenterology, Hepatology and Metabolic Disorders, Research Institute of Pediatrics and Child Health, Clinical Research Center No. 2 of the Petrovsky National Research Centre of Surgery, Professor at the Department of Faculty Pediatrics, Institute of Motherhood and Childhood, Pirogov Russian National Research Medical University of the Russian Ministry of Health (Pirogov University), Member of the Union of Pediatrists of Russia.
Tyazheva Alena Alexandrovna – Candidate of Medical Sciences, Associate Professor at the Department of Children's Diseases, Samara State Medical University of the Russian Ministry of Health, Professor at the Department of Pediatrics with a Course of Pediatric Surgical Diseases, Medical Institute of the Belgorod State National Research University, Member of the Society of Pediatric Gastroenterologists, Hepatologists and Nutritionists, Member of the Union of Pediatrists of Russia.
Khavkin Anatoly Ilyich – Doctor of Medical Sciences, Professor, Head of the A.V. Mazurin Department of Gastroenterology and Dietetics, Head of the Moscow Regional Center of Pediatric Gastroenterology and Hepatology, Research Clinical Institute of Childhood of the Ministry of Health of the Moscow Region; Professor at the Department of Pediatrics with a Course of Pediatric Surgical Diseases, Medical Institute of the Belgorod State National Research University, Chairman of the Society of Pediatric Gastroenterologists, Hepatologists and Nutritionists of Russia, Member of the Union of Pediatrists of Russia.
Efendieva Kamilla Evgenyevna – Candidate of Medical Sciences, Deputy Head for International Relations and Educational Activities, Leading Researcher, Allergist-Immunologist, Research Institute of Pediatrics and Child Health, Clinical Research Center No. 2 of the Petrovsky National Research Centre of Surgery, Associate Professor at the Department of Faculty Pediatrics, Institute of Motherhood and Childhood, Pirogov Russian National Research Medical University of the Russian Ministry of Health (Pirogov University), Member of the Union of Pediatrists of Russia.
Conflict of interest:
The authors declare no financial support or conflicts of interest that need to be disclosed.
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience for these clinical guidelines:
1. Target audience of these clinical guidelines:
Pediatricians
General practitioners (family physicians)
Gastroenterologists
Endoscopists
Medical students
Residents
Methods used to assess the quality and strength of evidence:
searching electronic databases. Description of methods used to assess the quality and strength of evidence: the evidence base for the recommendations includes publications included in the Cochrane Library, EMBASE, MEDLINE, and PubMed databases. Search depth — 10 years;
expert consensus;
assessment of significance in accordance with the rating scheme.
Table 1. Scale for assessing the levels of evidence (LE) for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1 | Systematic reviews of studies with reference standard control or systematic reviews of randomized controlled trials with meta-analysis |
2 | Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | Only justification of mechanism of action or expert opinion is available |
Table 2. Scale for assessing the levels of evidence (LE) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)
LoE | Definition |
|---|---|
1 | Systematic review of RCTs with meta-analysis |
2 | Individual RCTs and systematic reviews of studies of any design except RCTs, with meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports or case series, case-control studies |
5 | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Table 3. Scale for assessing the grades of recommendation (GR) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)
GoR | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
B | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Procedure for updating clinical guidelines.
The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.
Appendix A3. Reference Materials
State Register of Medicines: https://grls.rosminzdrav.ru
Order of the Russian Ministry of Health No. 205n dated May 2, 2023, "On Approval of the Nomenclature of Positions of Medical and Pharmaceutical Workers."
Order of the Ministry of Health and Social Development of the Russian Federation No. 541n dated July 23, 2010, "Unified Qualifications Handbook of Positions of Managers, Specialists, and Employees, Section: Qualification Characteristics of Healthcare Worker Positions."
Federal Law No. 489-FZ dated December 25, 2018, "On Amendments to Article 40 of the Federal Law 'On Compulsory Medical Insurance in the Russian Federation' and the Federal Law 'The Fundamentals of Protecting the Health of Citizens in the Russian Federation' regarding Clinical Guidelines."
Order of the Russian Ministry of Health No. 103n dated February 28, 2019, "On approval of the procedure and timelines for the development of clinical guidelines, their revision, the standard template of clinical guidelines, and requirements for their structure, composition, and scientific validity of the information included in the clinical guidelines."
Order of the Ministry of Health of the Russian Federation No. 804n dated October 13, 2017, "On Approval of the Nomenclature of Medical Services."
Order of the Russian Ministry of Health No. 1094n dated November 24, 2021, "On Approval of the Procedure for Prescribing Medicinal Products, Prescription Form Templates for Medicinal Products, the Procedure for Issuing, Accounting, and Storing Such Forms, Prescription Form Templates Containing Prescriptions for Narcotic Drugs or Psychotropic Substances, the Procedure for Their Manufacture, Distribution, Registration, Accounting, and Storage, as well as the Rules for Issuing Prescription Forms, Including in the Form of Electronic Documents."
Order of the Ministry of Health and Social Development of the Russian Federation No. 366n dated April 16, 2012, "On Approval of the Procedure for Providing Pediatric Care."
Order of the Russian Ministry of Health No. 203n dated May 10, 2017, "On Approval of Criteria for Assessing the Quality of Medical Care."
Order of the Ministry of Health of the Russian Federation No. 1008n dated September 23, 2020, "On Approval of the Procedure for Providing Patients with Therapeutic Nutrition."
Order of the Russian Ministry of Health No. 1122n dated December 6, 2021, "On Approval of the National Schedule of Preventive Vaccinations, the Schedule of Preventive Vaccinations for Epidemic Indications, and the Procedure for Administering Preventive Vaccinations."
"Methodological Guidelines MU 3.3.1.1095-02. 3.3.1. Vaccine Prophylaxis. Medical Contraindications to Preventive Vaccinations with National Immunization Schedule Preparations. Methodological Guidelines."
Appendix A3.1 Organic causes of recurrent abdominal pain in children [30]
Gastrointestinal Metabolic disorders
Celiac disease Adrenal crisis
Chemical gastritis Diabetic ketoacidosis
Constipation Porphyria
Eosinophilic esophagitis Neurological disorders
Erosive esophagitis Transverse myelitis
Gallbladder disease Spinal cord tumors
Gastroenteritis/colitis Musculoskeletal
disorders
H. pylori-associated infection Anterior cutaneous nerve
Hiatal hernia entrapment syndrome
Inflammatory bowel disease of the abdominal wall
Irritable bowel syndrome
Pancreatitis
Peptic ulcer disease
Diseases of the genitourinary system Other causes
Endometriosis Familial Mediterranean fever
Hymenal atresia IgE-mediated food allergy
Menstrual pain Lead poisoning
Ovulation pain Lymphoma
Ovarian cysts Peritoneal abscess/tumor
Pelvic inflammatory Pneumonia
disease Polyarteritis nodosa/vasculitis
Recurrent urinary tract infections Sickle cell anemia
Testicular pain
Pelviureteric junction obstruction/stenosis
Urolithiasis
Appendix B. Physician Action Algorithms
Diagnostic and treatment algorithm for functional dyspepsia in children
Option 1
Algorithm for selecting a treatment program based on diagnostic capabilities, including verification of H. pylori (in patients with signs of FD and presence of alarm symptoms, persistence of complaints despite prior therapy in epigastric pain syndrome, suspected HP infection [family history of peptic ulcer disease, gastric cancer, refractory iron deficiency anemia, idiopathic thrombocytopenic purpura]) [78, 79]
Diagnostic capabilities | Decision | ||||
|---|---|---|---|---|---|
№ | EGD | Diagnostic tests (invasive and non-invasive) | Pathological anatomical (histological) examination | Definition of resistance resistance to systemic antimicrobial drugs | |
1 | + | + | + | + | Individual treatment program taking into account H. pylori susceptibility |
2 | + | + | + | - | Standard 1st-line regimen taking into account regional data and individual characteristics of the child |
3 | + | + | - | - | Standard 1st-line regimen in the presence of absolute indications |
4 | - | + | - | - | Referral for EGD |
5 | - | - | - | - | Referral for EGD |
Diagnostic algorithm for recurrent abdominal pain and other clinically significant symptoms in children according to [30] with modifications
Appendix C. Patient Information
FD is a biopsychosocial disorder of the upper gastrointestinal tract, underpinned by social maladjustment, psychological stress, fatigue, sleep, study, and rest schedule disturbances, medication use (e.g., ibuprofen**, paracetamol**, acetylsalicylic acid**, antibiotics), food allergy, and Helicobacter pylori (H. pylori) infection.
Currently, a microorganism called H. pylori is recognized as an important factor causing FD. If confirmed, indicated treatment aimed at eradicating this microorganism must be carried out, followed by a check of treatment efficacy in 4-6 weeks. If the treatment fails, a repeated course of therapy with a different drug regimen should be performed. It is important to adhere to the treatment and strictly monitor medication intake to increase treatment efficacy, and strictly follow the doctor's recommendations. In the absence of H. pylori, treatment is carried out in accordance with the identified complaints and existing guidelines.
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
Not applicable.