Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Practice Guideline
. 2025 Aug;81(2):442-471.
doi: 10.1002/jpn3.70070. Epub 2025 May 30.

ESPGHAN/NASPGHAN guidelines for treatment of irritable bowel syndrome and functional abdominal pain-not otherwise specified in children aged 4-18 years

Jip Groen  1   2   3 , Morris Gordon  4 , Ashish Chogle  5 , Marc Benninga  1 , Rachel Borlack  6 , Osvaldo Borrelli  7 , Anil Darbari  8 , Jernej Dolinsek  9 , Julie Khlevner  10 , Carlo Di Lorenzo  11 , Hannibal Person  12 , Rinarani Sanghavi  13 , Julie Snyder  14 , Nikhil Thapar  15 , Arine Vlieger  16 , Vasiliki Sinopoulou  17 , Merit Tabbers  1 , Miguel Saps  18
Affiliations
Practice Guideline

ESPGHAN/NASPGHAN guidelines for treatment of irritable bowel syndrome and functional abdominal pain-not otherwise specified in children aged 4-18 years

Jip Groen et al. J Pediatr Gastroenterol Nutr. 2025 Aug.

Abstract

Objectives: Abdominal pain related disorders of gut-brain interaction (AP-DGBIs) such as irritable bowel syndrome (IBS) and functional abdominal pain-not otherwise specified (FAP) are common conditions in children, significantly impacting quality of life. This treatment guideline for IBS and FAP in children of 4-18 years is a collaborative effort of the European and North American Societies for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN and NASPGHAN). We aim to comprehensively review the current evidence on treatment options and offer evidence-based recommendations with utility across all treatment settings worldwide, as well as to provide methodological directions for future research.

Methods: The guideline development followed the "Grading of Recommendations Assessment, Development and Evaluation" (GRADE) approach, which is in accordance with the GRADE handbook and supported by the World Health Organization. The Guideline Development Group (GDG) comprised clinical experts, representing ESPGHAN, NASPGHAN, and Cochrane. Individual members have put forward a final consensus list of treatment options, which were then translated into "patient, intervention, comparison, outcome" (PICO) format options. Prospective agreement on decision thresholds for efficacy and safety outcomes was reached through a Delphi process among the GDG to support GRADEing of the literature. Consensus voting was used to finalize recommendations, and a treatment algorithm was developed.

Results: Systematic literature searches for this output identified 86 original randomized controlled trials assessing treatment of IBS and FAP. Consensus was reached for 25 GRADEd recommendations. Ten best practice statements were formulated, and guidance for future research methodology was proposed.

Conclusion: This guideline represents the first collaborative output of ESPGHAN and NASPGHAN on treatment options for AP-DGBIs. Systematic review of the evidence has exposed major evidence gaps for the treatment of these disorders and incentivizes large pediatric trials, particularly on treatment options for which, to date, no evidence exists.

Keywords: disorders of gut brain interaction; functional abdominal pain; gut‐brain psychotherapies; irritable bowel syndrome; pediatric.

PubMed Disclaimer

Conflict of interest statement

Regulations for conflict of interest followed the Cochrane handbook as well as the GRADE body. These implied that not only the receipt of financial contributions of institutions with links to assessed treatment options implied a conflict, but academic involvement in research on a specific treatment option without commercial funding as well. Marc Alexander Benninga indicated conflicts of interest for Cognitive Behavioral Therapy (CBT), Yoga, Hypnotherapy, and laxatives, due to involvement in studies assessing these therapies. Marc Alexander Benninga also indicated consulting services for Norgine, Coloplast, Wellspect, Allergan, Mallinckrodt, United Pharmaceuticals, Danone, FrieslandCampina, and HIPP. Marc Alexander Benninga also served as speaker for Abbott and Menarini. Ashish Chogle indicated a conflict of interest for neurostimulation, due to involvement in studies assessing these therapies. Julie Khlevner indicated a conflict of interest for laxatives, due to involvement in studies assessing these therapies. Julie Khlevner also indicated consulting services for Abbvie Inc. Carlo Di Lorenzo indicated conflicts of interest for neurostimulation, amitriptyline, linaclotide, and prucalopride, due to involvement in studies assessing these therapies. Miguel Saps indicated conflicts of interest for amitriptyline and linaclotide, due to involvement in studies assessing these therapies. Miguel Saps also indicated consulting services for Abbvie Inc., IQVIA, and Focus Medical Communications. Nikhil Thapar indicated conflicts of interest for probiotics, due to receiving honoraria from both Biogaia and Nutricia for roles in the advisory board and in moderating a key opinion leaders meeting on the addition of pre‐/probiotics in infant formula, respectively. Arine Vlieger indicated a conflict of interest for Hypnotherapy, due to involvement in studies assessing these therapies. Arine Vlieger also indicated an unpaid position as Chair of the Dutch Society for Hypnosis in Children. The remaining authors declare no conflicts of interest.

Figures

Figure 1
Figure 1
Treatment algorithm for irritable bowel syndrome (IBS); The “Grading of Recommendations Assessment, Development and Evaluation” (GRADE) data synthesis is the primary source informing the flow of treatments. However, best practice statements and additional considerations have also been included as they may be of additional value. The suggested flow provides a framework for shared decision‐making. The choice of any particular treatment option should strongly reflect the balance of efficacy and safety from an individual patient perspective, local availability and feasibility, and potentially legal frameworks. The consecutive order of treatments as proposed in this algorithm, may as such be modified following local context. Time to manifestation of treatment effect may vary depending on the chosen treatment option. Evaluation should be performed accordingly. IBS‐C, constipation; IBS‐D, diarrhea. §For choosing a laxative, use the European and North American Societies for Gastroenterology, Hepatology and Nutrition (ESPGHAN/NASPGHAN) guidelines on functional constipation. *Despite low certainty evidence supporting efficacy to treat abdominal pain disorders of gut–brain interaction symptoms, the consensus among the guideline's authors is that they lack sufficient experience in using domperidone in clinical practice.
Figure 2
Figure 2
Treatment algorithm for Functional Abdominal Pain‐Not Otherwise Specified (FAP); The “Grading of Recommendations Assessment, Development and Evaluation” (GRADE) data synthesis is the primary source informing the flow of treatments. However, best practice statements and additional considerations have also been included as they may be of additional value. The suggested flow provides a framework for shared decision‐making. The choice of any particular treatment option should strongly reflect the balance of efficacy and safety from an individual patient perspective, local availability and feasibility, and potentially legal frameworks. The consecutive order of treatments as proposed in this algorithm may as such be modified following local context. Time to manifestation of treatment effect may vary depending on the chosen treatment option. Evaluation should be performed accordingly. *Despite low certainty evidence supporting efficacy to treat abdominal pain disorders of gut–brain interaction symptoms, the consensus among the guideline's authors is that they lack sufficient experience in using domperidone in clinical practice.
Figure 3
Figure 3
Infographic describing the contents of the evidence boxes presented for each treatment option discussed in this guideline.CI, confidence interval; GRADE, Grading of Recommendations Assessment, Development and Evaluation; SMD, standardized mean difference.
See this image and copyright information in PMC

References

    1. Korterink JJ, Diederen K, Benninga MA, Tabbers MM. Epidemiology of pediatric functional abdominal pain disorders: a meta‐analysis. PLoS One. 2015;10(5):e0126982. - PMC - PubMed
    1. Youssef NN, Atienza K, Langseder AL, Strauss RS. Chronic abdominal pain and depressive symptoms: analysis of the national longitudinal study of adolescent health. Clin Gastroenterol Hepatol. 2008;6(3):329‐332. - PubMed
    1. Hoekman DR, Rutten JMTM, Vlieger AM, Benninga MA, Dijkgraaf MGW. Annual costs of care for pediatric irritable bowel syndrome, functional abdominal pain, and functional abdominal pain syndrome. J Pediatr. 2015;167(5):1103‐1108.e2. - PubMed
    1. Lewis ML, Palsson OS, Whitehead WE, van Tilburg MAL. Prevalence of functional gastrointestinal disorders in children and adolescents. J Pediatr. 2016;177:39‐43.e3. - PubMed
    1. Assa A, Ish‐Tov A, Rinawi F, Shamir R. School attendance in children with functional abdominal pain and inflammatory bowel diseases. J Pediatr Gastroenterol Nutr. 2015;61(5):553‐557. - PubMed

Publication types

Grants and funding