ANNALS OF GASTROENTEROLOGY 2004, 17(2):173180
Original article
Dyspepsia in childhood. Clinical manifestations and management
K. Spiroglou1, G. Paroutoglou2, N. Nikolaides2, I. Xinias1, Olga Giouleme2,
G. Arsos1, Vasiliki Demertzidou1, N. Eugenides2
SUMMARY
Objectives: In recent studies there is little data regarding
functional dyspepsia in childhood. This study aimed to
determine the frequency, clinical manifestations and
treatment of functional dyspepsia in childhood.
Methods: The study sample consisted of 548 children
with recurrent abdominal pain (age range: 4-14
years). A standardized questionnaire was used to
investigate the symptoms of functional dyspepsia as
recorded in similar studies for adults. Baseline laboratory
tests were carried out for each patient. Additionally, the
severity of clinical manifestations and the presence of
accompanying symp- toms, which might trigger or
exacerbate the condition, were investigated. Prokinetic or
acid-reducing drugs were used according to the judgment
of the attending pediatrician.
Results: Finally 348 children (180 male, 168 female) met
the inclusion criteria. Children within severe form of
dyspepsia had more frequent nausea (p<0.0001), vomiting
(p<0.0001) and belching (p<0.0001), while children with a
moderate form of dyspepsia had postprandial fullness
(p<0.002) and bloating (p<0.0001). The frequency of
functional dyspepsia was 70.73%. Paleness (p<0.0001) was
the most frequent symptom in organic dyspepsia whereas
epigastric pain was more prevalent in functional
dyspepsia (p<0.007). As far as the treatment of these
patients was concerned, children treated with
cisapride responded
Department of Pediatrics, 3rd Pediatric Clinic, Division of Digestive
Diseases and 2Department of Gastroenterology, Aristotle University
of Thessaloniki, Hippocration Hospital, Thessaloniki, Greece
1
Author for correspondence:
Kleomenis Spiroglou, Associate Professor of Pediatrics, Aristotle
University of Thessaloniki, Department of Pediatrics, 3rd Pediatric
Clinic, Hippocration Hospital, Greece, Tel.: 0030310274096,
marginally
ranitidine.
better
than
those
who
received
Conclusions: The frequency of functional dyspepsia in
childhood reached a percentage of 70%. The majority of
patients exhibited mild disease manifestations whereas
the most frequent symptoms of the condition were
nausea, vomiting, belching, bloating and postprandial
fullness. Therapeutically, cisapride seemed to be
superior to acid- reducing drugs but in a non significant
manner.
Key words: Dyspepsia, functional dyspepsia, recurrent abdominal painIntroduction
The most common complaint in children aged 4 to
14 years, is recurrent abdominal pain (RAP), which
represents a heterogeneous group, encompassing both
organic diseases and functional gastrointestinal disorders1,2.
A large number of these children report an uncomfortable feeling localized in the upper abdomen and
symptoms of dyspepsia, as defined in adults 3,4. When
these symptoms cannot be explained by structural,
biochemical or histological abnormalities they are
considered to be functional dyspepsia5.
A review of the recent literature indicates that even
though dyspepsia is common in adults, only limited data
regarding dyspepsia in children is available. Spiroglou
et al6, in a recent study, found over 50% of their patients,
to have functional dyspepsia with the more commonly
encountered symptoms being nausea, vomiting, early
satiety, awaking from sleep and increased belching.
Hyams et al7, in a prospective study, found, after esophagogastroduodenoscopy and biopsy, 35 out of 56
patients (62.5%) have functional dyspepsia.
The goals of this study were to investigate and record
the incidence and clinical manifestations of dyspepsia in
ANNALS OF GASTROENTEROLOGY 2004, 17(2):173180
174
childhood, to evaluate any relationship between primary
(functional) and secondary dyspepsia and to clarify the
management of these children.
K. SPIROGLOU, et al
Table 1. Dyspepsia severity score
Score
Intensity of pain:
MATERIAL AND METHODS
During a period of about 5 years (June 1996 to June
2001) 528 consecutive children 4 -14 years of age were
referred to the outpatient clinic of the 3rd Department of
Pediatrics, Division of Digestive Diseases (Aristotle
University of Thessaloniki, Greece) with recurrent
abdominal pain (RAP). All of them, (271 boys and 257
girls) were included in the study.
Children with organic diseases known to cause dyspeptic symptoms or recently receiving (the previous three
months) antibiotics or anti-inflammatory drugs (NSAIDS),
as well as children with swallowing difficulties, altered
bowel pattern (diarrhea, fecal soiling or constipation) and
viral infections in the last three months were excluded
from the study.
During the initial consultation, special interest was
paid to information regarding the character of abdominal
pain (location, duration, nature and frequency). Other
questions asked included dyspeptic symptoms for adults
as referred to in different reports3-5. Any relationship between dyspeptic symptoms with specific events such as
fever, blood in the stool or emesis, involuntary weight
loss or growth deceleration, anemia, elevated ESR, relief
by food, as well as possible relationships with factors
(eg. meals, stress, sleep) that could alleviate or
precipitate the patients abdominal pain were sought.
Information was compiled by one of the investigators
(KS, VD, PG, IX) and was supplied by both the parents
and the child. The consultation was completed with
questions regarding family history of gastrointestinal
disorders, absenteeism from school, death in the
family, school problems, overprotective parents,
divorce, financial problems and symptoms like
headache, migraine, sweating, pallor, dizziness or any
strange and unexplained feelings. As, in our experience,
many children, especially those of under
6 or 7 years of age could not define which one symptom
was more prominent, we used a scale to define the
severity of dyspepsia. This scale (Table 1) consisted of a
questionnaire, which was a modified version of the Glasgow Dyspepsia Severity Score8, for the last six months
preceding the initial consultation. It tried to evaluate the
frequency of abdominal pain (predominant symptom),
the number of school or preschool days of absenteeism,
the duration and intensity of pain, the presence of
nocturnal pain and vomiting. Scores ranged from 0 to
Duration of pain:
Incidence of pain:
Mild
Moderate
Severe
<15
15 60
>60
Once every 10 days
2 5 times weekly
Every day
Nocturnal awakens: Never
Absenteeism:
Vomiting:
Rarely*
Usually
Less than one day every week
One day every week
More than one day every week
Never
Rarely**
Usually
* at least two times for the last three months
** 2 - 4 times during the last three months
16, with high scores indicating grater severity.
According to this scale we divided patients with
dyspepsia into three groups: mild (score <6), medium
(score 7 - 10) and severe (score >11) forms.
The thorough physical examination was completed
with a search of areas of tenderness, palpable stools in
the left lower quadrant and amount of stool in the rectal
ampulla. The initial evaluation included the use of
routine and easily obtainable studies (full blood evaluation, erythrocyte sedimentation rate, aspartate aminotransferase, serum bilirubin, serum albumin, serum
amylase, urinalysis, stool for ova and parasites, serum
creatinine and electrolytes) for the determination of
conditions such as parasitic infections, biliary tract or
hepatic diseases, pancreatitis, irritable bowel syndrome
or other organic causes of abdominal pain.
If a satisfactory diagnosis, was not obtained
additional studies were performed at the discretion of the
examining physician. These included breath hydrogen
testing for lactose malabsorption, ultrasonography and
esophageal
24-hour pH monitoring. Upper gastrointestinal endoscopy to rule out esophagitis, peptic ulcer disease,
Helicobacter pylori infection or esophagitis was performed in all children with medium and severe dyspepsia.
Dyspepsia in childhood
Children under seven years of age were hospitalized and
examined under general anesthesia, while children older
than seven years of age were examined after conscious
sedation with midazolam (0.15-0.20 mg/kg, IV) and
ketamine hydrochloride (1-2 mg/kg, IV)6. In all patients
undergoing the procedure, biopsies were taken for CLO
test (Delta West Ltd) and routine histology; these
comprised one duodenal biopsy, two antral and one or
two from the esophagus. The presence of inflammation
was judged by the quality and quantity of the cellular
infiltrate in the mucosa, using generally accepted
9,10
criteria . Although the presence of Helicobacter pylori
infection was also checked in the serum or by CLO test,
the final diagnosis was based on histology.
All patients with gross evidence of inflammation in
the upper gastrointestinal tract (esophagitis, duodenitis,
gastritis, and ulcer) received acid-reducing drugs (ranitidine 5 mg/Kg daily for 4 weeks). Antibiotic therapy
(amoxicillin 50 mg/Kg and clarithromycin 15 mg/Kg,
daily) was used only for patients with Helicobacter
pylori infection. Children with mild Helicobacter pylori
negative gastritis and children with normal
endoscopic and histologic findings (functional
dyspepsia) were treated with promotility drugs
(cisapride 0.8 mg/Kg daily in four doses for 6 weeks) or
acid reducing drugs (ranitidine) at the discretion of the
attending pediatrician.
Patients were observed on return visits at 1, 6 and 12
months. If no return, by telephone contact was made. At
12 months return or telephone contact, a re-evaluation
was made for diagnosis and treatment. Additional
symptoms, diagnostic studies or treatment changes were
noted.
Definitions. Dyspepsia was classified as persistent or
recurrent abdominal pain and/or discomfort, localized
in the upper abdomen for a period of at least three
months with normal biochemical tests, imaging investigations and histology findings11. Acid regurgitation and/
or pain in the chest were considered as gastroesophageal
reflux12. Irritable bowel syndrome was classified as any
case
with the presence of abdominal pain or discomfort
which
was relieved by defecation and usually associated with a
change in stool frequency or consistency (hard loose),
in the absence of demonstrable disease. Frequently it is
accompanied with a sense of incomplete evacuation,
bloating, straining, urgency and the passage of mucus
from the rectum13.
Statistical analysis. Calculations and statistical
analysis were made for all patient symptoms by
175
Comparisons between various groups were made by chisquare test. Statistical significance was accepted when
p<0.05.
RESULTS
a. Diagnostic approach Clinical presentation
Based on detailed history, clinical examination and
basic laboratory work-up, various organic diseases were
identified as the cause of RAP in sixty-five (12.31%)
children. Ninety-three (17.61%) children had clinical
manifestations similar to adult irritable bowel syndrome
and 22 (4.16%) additional children with RAP had typical
or suspected GOR disease. All the above mentioned
children were excluded from the study.
he remaining 348 children (180 males and 168
females, mean age 6.942.33 years) fulfilled the
diagnostic criteria for dyspepsia and served as the study
population. Abdominal pain, being the predominant
symptom, was epigastric in location in 132 children and
diffuse or periumbilical in 216 (Table 2). Children with
epigastric pain were older than those with diffuse
abdominal pain (mean age 7.52.38 years vs 61.98
years, p<0.0001). Pain was often combined with nausea,
vomiting, anorexia, nocturnal awakening etc.
In relation to severity of dyspepsia (mild, moderate,
severe) children with mild dyspepsia suffered more
frequently from diffuse abdominal pain (73.6%), in
contrast to children with moderate or severe dyspepsia,
where epigastric pain was predominant (81.8%, p<0.001)
(Table 2). Moreover, children with moderate or severe
dyspepsia presented higher frequency of nausea
(p<0.0001), vomiting (p<0.0001) and belching (p
<0.0001), and lower frequency of postprandial fullness
(p=0.002) and bloating (p<0.0001) compared with
children with mild dyspepsia. The frequency of the rest
of the symptoms did not significantly differ between the
two groups (Table 3).
Because of the increased likelihood for secondary
computer support. Data are present by descriptive
statistics.
Dyspepsia in childhood
dyspepsia, children with moderate or severe dyspepsia
submitted to endoscopy. Results of endoscopy along
with histological findings are presented in table 4.
The diagnosis of functional dyspepsia was considered in
116 children (70.73%) with normal endoscopic
findings. Children with abnormal endoscopic
findings were properly managed and excluded from
the study. With the exception of paleness, which was
more frequent in children with secondary dyspepsia
(p<0.0001), no other difference in symptom frequency
was found between
175
176
K. SPIROGLOU, et al
Table 2. Incidence of symptoms in the different subgroups of dyspepsia
Children investigated
184
115
49
348
Symptoms
Mild
Moderate
Severe
Total
Abdominal pain:
Pain in the epigastrium
Periumbilical or diffuse
24 (13.04%)
62
(53.9%)
46
(93.8%)
132
(37.9%)
49
(42.6%)
(16.3%)
216
(62%)
159
(86.4%)
Nausea
46
(25%)
55 (47.82%)
34 (69.38)
135 (38.79)
Vomiting
33 (17.93%)
48 (41.73%)
25 (51.02%)
106 (30.45%)
Nocturnal awakens
49 (26.63%)
28 (24.34%)
14 (28.34%)
91 (26.14%)
Early satiety
37
(20.1%)
29 (25.21%)
13 (26.53%)
79
Belching
33 (17.93%)
39 (33.91%)
25 (51.02%)
97 (27.87%)
Anorexia
25 (13.58)
15 (13.04%)
7 (14.28%)
47 (13.05%)
Postprandial fullness
69
26
(22.6%)
12 (24.48%)
107 (30.74%)
Abdominal bloating
71 (38.58%)
25 (21.73%)
6 (12.24%)
102 (29.31%)
headache*
16
(8.69%)
18 (15.65%)
7 (14.28%)
41 (11.78%)
sweatiness
11
(5.97%)
(6.08%)
(8.16%)
22
(6.32%)
paleness
(2.71%)
(5.21%)
(8.16%)
15
(4.31%)
tachycardia
(3.26%)
(6.95%)
(6.12%)
17
(4.88%)
(37.5%)
(22.7%)
Other symptoms
* Four children aged 5, 6, 8 and 10 years old, had migraine (two with familial history)
Table 3. Relationship of dyspeptic symptoms with dyspepsia severity and different forms of dyspepsia
Dyspepsia severity
Frequency of symptoms between
functional and secondary dyspepsia
Symptom
Mild
Moderate
Functional
Dyspepsia
184 cases
or severe
dyspepsia
as a secondary
164 cases
116 cases
symptom 48 cases
Postprandial abdominal
bloating/or distension
69
38
0.002
25
13
NS
Anorexia
25
22
NS
17
10
NS
Pain awakens
49
42
NS
27
15
NS
Headache
16
25
NS
17
08
NS
Nausea
47
89
0.0001
62
27
NS
Pallor
05
10
NS
02
08
0.0001
Early satiety
37
42
NS
43
19
NS
Belching
33
64
0.0001
47
16
NS
Sweat
11
11
NS
06
05
NS
Tachycardia
06
11
NS
06
05
NS
Fullness
71
31
0.0001
22
09
NS
Vomiting
33
73
0.0001
50
23
NS
85
24
0.007
Epigastric pain
these children and children with functional dyspepsia.
However, children with functional dyspepsia suffered
more often from epigastric pain (p<0.007), whereas in
children with secondary dyspepsia periumbilical or
Dyspepsia in childhood
177
Table 4. Endoscopic and histologic evaluation of children with
moderate to severe dyspepsia
Helicobacter pylori
Positive*
Peptic ulcer
Esophagitis
Negative
**
Severe gastritis
15
Mild superficial gastritis
) Group with endoscopic examination
21
Eosinophilic gastritis
Duodenitis
Functional dyspepsia
B1) Children with mild, Helicobacter pylori
negative gastritis (n=21)
116
Total
20
at the discretion of the attending pediatrician. Response
to therapy was classified as: a) non or partial response b)
full response at the end of the 3, 6 and 12 months. By the
end of 12 months (Table 5), more children given
cisapride had achieved full remission compared to
those given ranitidine (56.43% vs. 28.84%, p=0.002).
144
* Helicobacter pylori infection was based on histological
evaluation
** 4 children with duodenal ulcer
diffuse pain was more common (Table 3). The prevalence
of Helicobacter pylori in children with recurrent
abdominal pain was found to be 13%.
b. Management
) Group without endoscopic examination
(n=184)
Children with mild dyspepsia were initially treated
empirically. Non-medical measures included repeated
discussions about the nature of the problem, encouragment of acceptance and reassurance about the benign
nature of the condition, and instructions for environment
improvement and modification. A number of children
responded to this therapy and remained symptom-free
on re-evaluation, three months after treatment initiation.
In particular, 47 children (25.54%) were symptom-free
at 3 months, but this percentage was reduced to 16.84%
(31 children) at 12 months. The remaining 153 children
received two different trials: 101 were given promotility
drugs (cisapride) and 52 acid-reducing drugs (ranitidine)
On lack of evidence to the contrary, the diagnosis of
functional dyspepsia was adopted and children were
symptomatically treated as having functional dyspepsia.
In particular, cisapride and ranitidine were empirically
given in 14 and 7 children respectively, at the discretion
of the attending pediatrician (Table 6). By the end of 12
months cisapride was more effective than ranitidine
(50.0% vs. 28.6%), but this difference was not
statistically significant (p=0.642), maybe due to the
small number of patients in the sample.
B2) Children with functional dyspepsia (normal
endoscopic and histological findings (116)
Ranitidine in 72 and cisapride in 44 children was
empirically given at the discretion of the attending
pediatrician (Table 7). Results concerning effectiveness
of cisapride vs. ranitidine (55.55% vs. 40.90%) are
similar to those of groups A and B1, thus confirming the
superior beneficial effect of cisapride, although to a
lesser extent than in the two previous groups. Results
again show an apparently better response to cisapride by
the end of the months 12 (55.55% vs. 40.90%), not
however, statistically significant (p=0.185).
There were no side effects or adverse reactions with
used drugs, except for diarrhea, which appeared in four
children during the first days of cisapride use. The drug
was discontinued for some days and restarted in smaller
doses (0.4-0.6/Kg, 3-4 times daily).
Table 5. Results of treatment in the mild dyspepsia (without endoscopic evaluation) group
Response
to treatment
Complete
remission
Non or partial
remission
Cisapride
Ranitidine
Cisapride
Ranitidine
Cisapride
Ranitidine
group
group
3rd
group
group
6th
group
group
12th
3rd month
101 cases
3rd month
52 cases
month
6th month
101 cases
3rd month
52 cases
month
12th month
101 cases
12th month
52 cases
month
69
(68.31%)
18
(34.61%)
0.0001
62
(61.38%)
17
(32.69%)
0.002
57
(56.43%)
15
(28.84%)
0.002
32
34
39
35
44
37
(31.68%)
(65.39%)
(38.61%)
(67.31%)
(43.56%)
(71.16%)
178
K. SPIROGLOU, et al
Table 6. Results of treatment in the mild (interstitial) Helicobacter pylori negative gastritis group
Response
to treatment
Cisapride
group
Ranitidine
group
Cisapride
group
Ranitidine
group
Cisapride
group
Ranitidine
group
3rd month
3rd month
6th month
3rd month
12th month
12th month
14
14
14
Complete
remission
8 (57.14%)
4 (57.14%)
7 (50%)
3 (42.57%)
7 (50%)
2 (28.57%)
Non or partial
6 (42.86%)
p
(12 month)
th
0.642 (NS)
3 (42.86%)
7 (50%)
4 (57.43%)
7 (50%)
5 (71.43%)
remission
Table 7. Results of treatment in the children with functional dyspepsia group
Response
to therapy
Cisapride
group
Ranitidine
group
Cisapride
group
Ranitidine
group
Cisapride
group
Ranitidine
group
3rd month
3rd month
6th month
3rd month
12th month
12th month
72
44
72
44
72
44
42 (58.33%)
19 (44.18%)
41 (56.94%)
18 (40.9%)
40 (55.55%)
18 (40.9%)
Non or partial 30 (41.67%)
25 (55.82%)
31 (43.06%)
26 (59.1%)
32 (44.45%)
26 (59.1%)
Complete
remission
p
(12th month)
0.185 (NS)
remission
DISCUSSION
Dyspepsia represents a common problem in adults,
occurring at a prevalence of 20%-40% and annual
incidence of 1.6%-8%14,15. It appears either as functional
or secondary to organic disease. According to the recent
literature, functional dyspepsia has been found in up to
60% of dyspeptic adults15. Although recent data indicates
that dyspepsia is common among adults, only limited
data about childhood dyspepsia is available. Recently
Hyams et al7 found an incidence of functional dyspepsia
to be as high as 62.5% and Boey et al16, up to 65.3%. In
a cohort of 164 children with a moderate or severe
form of dyspepsia which was assessed by detailed
history, clinical examination, basic laboratory tests and
endoscopy, we found functional dyspepsia at a
prevalence of 70.7%, slightly higher than that reported
in the previous studies.
Clinical manifestations of dyspepsia in adults have
been well described and include epigastralgia or
discomfort followed by nausea, vomiting, postprandial
fullness, early satiety etc4,14,15. According to Chelimski
and Czinn17 symptoms in children are classified as
major (epigastric pain, vomiting) and minor
(regurgitation, anorexia, nocturnal awakening etc.). In
this study we found that clinical manifestations were not
substantially different from those in adults. However,
the severity of
178
dyspepsia
was milder or more moderate in children. Of
348 children, dyspeptic manifestations were severe in
only
49 (14.1%). Abdominal pain, mainly epigastric (81.8%),
was the predominant symptom, often accompanied by
belching, nausea, vomiting, postprandial fullness and
bloating. Nausea, vomiting and belching were
statistically more frequent in the moderate and severe
cases, as opposed to mild cases in which postprandial
fullness and bloating dominated.
No statistically significant differences were found in
the frequency of symptoms between children with organic
and functional dyspepsia, with two notable exceptions.
Epigastric pain was more frequently associated with
functional dyspepsia whereas paleness was more frequently associated with organic dyspepsia. Similarly to
Hyams et al 7, we were also unable to distinguish the
clinical subgroups of dyspepsia in the way described in
adults, namely the ulcer-like or dysmotility-like
dyspepsia. The reason for this could be twofold: a) the
inability of children (especially those younger than 6-7
years old) to accurately perceive and verbalize dyspeptic
symptoms and b) the limited experience of pediatricians
to evaluate these symptoms.
The use of endoscopy as a first level investigation for
the diagnosis of dyspepsia is questionable. Some
K. SPIROGLOU, et al
Dyspepsia in childhood
authors18,19 consider recurrent abdominal pain to be an
indication for endoscopy. However, others suggest that
endoscopy should be avoided because of the discomfort
caused to the pediatric patient and its limited diagnostic
value6,20. According to Maastricht consensus21 and the fact
that in children malignancies of the gastrointestinal tract
are extremely rare and peptic ulcer disease is uncommon
(no more than 5%), we consider that endoscopy could
not be a first-level diagnostic tool in childhood
dyspepsia. In our study, endoscopy was carried out on
164 children with moderate to severe symptoms or
frequent relapse of dyspepsia, since these groups are
suggestive of possible underlying organic disease. It has
been reported that mild, superficial, Helicobacter pylori
negative gastritis is not a distinct entity22,23 and
Helicobacter pylori in the absence of duodenal ulcer is
not a cause of symptoms 24,25. In this study dyspeptic
symptoms were attributed, after endoscopy, to a specific
organic disease in only 12 cases (7,3%), namely peptic
ulcer (n=5), oesophagitis (n=3), eosinophilic gastritis
(n=1), duodenitis (n=3) (Table 4). This is a lower than
that reported in adult studies (40%)14,15 and therefore it
does not justify the use of endoscopy as a primary
diagnostic tool in the evaluation of dyspepsia during
childhood. We did not notice any difference in the
prevalence of Helicobacter pylori in children with
recurrent abdominal pain compared to control participants (13% vs. 11.4%)26.
To date, it is controversial whether mild epithelial or
interstitial inflammation without discrete ulceration or
evidence of Helicobacter pylori infection causes
symptoms of dyspepsia17. According to some
authors 12,17,27 a mild epithelial or interstitial
inflammation is considered a normal condition. In our
study, we found 21 such cases with histologic findings
of interstitial inflammation without Helicobacter pylori
infection. Until more data is available, all these cases
were considered as functional dyspepsia.
In young patients with functional dyspepsia who are
Helicobacter pylori negative, it is recommended that a trial
of acid-reducing drugs (e.g. histamine H 2-receptor
antagonist, antacid, proton pump inhibitor) or promotility drugs (cisapride, metoclopramide) be prescribed for
one month28,29. If this fails to relieve symptoms, therapy
may be switched between antisecretory and prokinetic
classes. If, after 8 weeks of therapy, symptoms persist or
rapidly recur on cessation of treatment, endoscopy is
recommended. The few studies that have directly
compared acid-suppressing and prokinetic agents in
adults have suggested that prokinetic agents are more
effective30. In our study, cisapride looked to be superior
179
to ranitidine but this difference was not statistically
significant (p=185).
In conclusion, we believe that functional dyspepsia is
an extremely common finding among children under the
broad spectrum of recurrent abdominal pain and it is
probably time to reconsider this general term. We suggest
that upper gastrointestinal endoscopy is not necessary
as a first-level evaluation in most cases of recurrent
abdominal pain, because the more severe organic reasons
of dyspepsia in adults (gastroesophageal reflux disease,
ulcer disease and tumor) are rather rare (ulcer, gastroesophageal reflux disease) or nonexistent (tumors) in
childhood. Cases with epithelial or interstitial inflammation without Helicobacter pylori can also be considered as cases of functional dyspepsia until more data is
available. Children with functional dyspepsia who are
negative for Helicobacter pylori, can be treated empirically according to the prominent symptoms using either
promotility or acid-reducing drugs, and be reevaluated
after four weeks.
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