Some Adult Disorders of the Gut–Brain Interaction According to Rome IV Criteria That May Occur in the Pediatric Age Group

1. Introduction

Disorders of the gut–brain interaction (DGBIs) constitute a group of conditions arising from the interplay of altered gastrointestinal motility and visceral sensitivity, dysfunction of the immune system and intestinal mucosa, imbalances in the gut microbiota (dysbiosis), and changes in the perception and central processing of gastrointestinal signals by the central nervous system [1], without identifiable structural or biochemical abnormalities that explain these symptoms [2].

In childhood, DGBIs are associated with a considerable symptom burden, accompanied by psychological distress, reduced quality of life, school and social absenteeism, increased healthcare costs, and parental work absenteeism [3], moreover, they are associated with a higher likelihood of persistence or progression of the disorder into adulthood [4]. It is estimated that approximately 25.0% of children with recurrent abdominal pain subsequently develop irritable bowel syndrome [3].

The Rome Committee periodically emits criteria that facilitate the diagnosis and identification of the pediatric population with DGBIs [5]. Over the past three decades, the Rome Criteria have been the main diagnostic tool for these disorders in children, being periodically updated based on recent scientific evidence and expert consensus; the most recent version, Rome IV, was published in 2016 [1] and we are currently on the verge of publication of the next version, scheduled for May 2026.

Some DGBIs are well defined in the adult population but have not yet been incorporated into the pediatric Rome Criteria. Such is the case of functional dysphagia [6,7], functional diarrhea [2,8], functional chest pain [9], functional biliary pain [10], as well as functional heartburn and proctalgia fugax [11].

According to adult criteria, functional dysphagia is characterized by the sensation of abnormal passage of the food bolus through the esophagus in the absence of structural, mucosal, or motor abnormalities [6]. Its diagnosis requires the exclusion of oropharyngeal causes of dysphagia, as well as structural lesions of the tubular esophagus, gastroesophageal reflux disease (GERD), eosinophilic esophagitis, and significant esophageal motility disorders [12]. Its etiological diagnosis is complex due to the overlap of clinical phenotypes and the lack of specific diagnostic guidelines for the pediatric population [7]. Functional diarrhea is characterized by the recurrent presence of liquid or semi-liquid stools without predominant abdominal pain or evidence of structural abnormalities [8]. It is a common disorder in young children, with studies conducted in different countries reporting a prevalence ranging from 1.9 to 2.5% in children under one year of age [2]. It should be noted that it is not included in the pediatric Rome IV Criteria for children aged 4 to 18 years old, as it was originally considered a diagnosis applicable only for younger children [2]. Nevertheless, in clinical practice, older children and adolescents may present symptoms consistent with this condition, suggesting the need to revisit its definition in future updates.

Functional chest pain presents as recurrent, unexplained retrosternal pain of presumed esophageal origin, not explained by mucosal or motor disorders, and distinct from heartburn-related pain, occurring at least once per week [9], while functional biliary pain is characterized by constant pain located in the epigastrium or the right upper quadrant of the abdomen, lasting at least 30 minutes, similar to biliary colic, in the absence of gallstones or biliary abnormalities [10] and functional heartburn is defined as an unpleasant sensation or retrosternal burning pain that does not respond to optimal antisecretory treatment, in the absence of GERD, histopathological alterations of the mucosa, relevant motor disorders, or other structural causes that explain it [6].

Finally, proctalgia fugax is characterized as chronic or recurrent rectal pain, described as pain or discomfort lasting at least 30 minutes, with no evidence of a structural or systemic cause [11]. According to the Rome IV Criteria for adults, the diagnosis of these disorders requires that symptoms have been present for at least three months, with symptom onset at least six months before evaluation, and that there be no evidence of a structural or metabolic disease to explain the symptoms [13]. However, it is important to note that these criteria have not yet been fully evaluated or validated in the pediatric population; therefore, their application should be approached with caution and clinical judgment.

Therefore, the aim of this study was to determine the prevalence of selected adult DGBIs according to the Rome IV Criteria using the Questionnaire for Pediatric Gastrointestinal Symptom Rome IV (QPGS-IV), adapted from adult criteria, in toddlers, school-aged children, and adolescents from public educational institutions in three Colombian cities.

2. Materials and Methods

A prospective, observational, cross-sectional study was conducted in toddlers, school-aged children, and adolescents aged 4 to 18 years old, from Public Educational Institutions in three Colombian cities: Cúcuta (Andean Region), Maicao (Caribbean Region) y Corozal (Caribbean Region). After obtaining informed consent/assent in children older than 7 years old, data collection was initiated through the administration of the QPGS-IV questionnaire, adapted with additional items corresponding to the diagnostic model used in adults. This adaptation allowed a more in-depth exploration of the presence of symptoms and conditions that, although more frequently described in adult population, may also manifest during childhood (functional dysphagia, functional diarrhea, functional chest pain, functional chest pain, functional biliary pain, functional heartburn and proctalgia fugax) (Table 1).

Likewise, sociodemographic variables (age, sex, race and place of origin), clinical variables (history of COVID-19 and COVID-19 vaccination status) were collected.

Aspects related to school and social absenteeism were also considered, including the reasons that led children or adolescents to miss their usual activities, as well as the assessment of their quality of life using the Pediatric Quality of Life Inventory™ Questionnaire (PedsQL), which allows the measurement of the impact of health problems across different dimensions of a child’s well-being. To explore psycho-emotional aspects, Patient-Reported Outcomes Measurement Information System (PROMIS) anxiety and depression were also applied, to assess the presence of anxiety and depression traits in the studied population.

The statistical analysis included calculation of measures of central tendency to describe the characteristics of the sample, as well as univariate and bivariate analyses to identify associations between variables. A multiple logistic regression analysis was also performed to determine the independent factors associated with the presence of adult DGBIs according to the Rome IV Criteria. Results were expressed as odds ratios (ORs) with their corresponding 95% confidence intervals (95% CIs), with a p value <0.05 considered as statistically significant.

This study was approved by the Ethics Committee of the Hospital Universitario Erasmo Meoz from Cúcuta, Colombia (approval No. 51-2024, dated July 30, 2024). In addition, a written authorization was obtained from the institutional authorities of the participating educational establishments.

3. Results

A total of 789 students from Public Educational Institutions in the cities of Cúcuta (Andean Region), Maicao (Andean Region), and Corozal (Andean Region) were invited to participate. Of these, 704 students completed the QPGS-IV questionnaire and the additional items on adult disorders and were therefore included in the final analysis. Among the included participants, 41 students met criteria for at least one adult DGBI (Figure 1).

3.1. DGBIs

According to the Rome IV criteria, 23.4% of students presented at least one DGBI, with functional constipation being the most frequent (18.0%), followed by postprandial distress–type functional dyspepsia (2.4%) and functional vomiting (1.0%). A total of 2.7% of students presented more than one DGBI; among the most frequent overlaps were functional dyspepsia + constipation (1.1%), followed by constipation + cyclic vomiting syndrome (0.6). The 5.8% (n=41) presented some DGBI described in adults according to the Rome IV Criteria: proctalgia fugax 2.8% (n=20), functional heartburn 1.0% (n=7), functional diarrhea 0.9% (n=6), functional dysphagia 0.6% (n=4), functional chest pain 0.4% (n=3) y functional biliary pain en 0.1% (n=1) (Table 2).

The main characteristics of all the participants between 4 and 18 years old and the 41 children with adult-onset DGBIs according to the Rome IV Criteria included in the study are presented in Table 3.

3.2. Possible Associations with the Presence of Adult DGBIs According to the Rome IV Criteria

The possible risk factors for presenting at least one adult DGBIs according to the Rome IV Criteria included being of Indigenous race (OR=2,36; 95% CI=1,02-5,06; p=0,0170), school absenteeism (OR=3,79; 95% CI=1,90-7,60; p=0,0000), social absenteeism (OR=5,90; 95% CI=2,93-12,03; p=0,0000,), depression traits (OR=3,97; 95% CI=1,73-9,49; p=0,0002) and to present an altered quality of life (OR=2,36; 95% CI=1,09-5,04; p=0,0135) (Table 4).

3.3. Logistic Regression Analysis

The multivariate logistic regression model, which included all variables that showed statistical significance in the bivariate analysis, showed that depressive traits and school and social absenteeism were the most important variables associated with the presence of adult DGBIs in pediatric population, behaving as factors significantly related to this outcome (OR=4,08; 95% CI=1,82-9,12; p=0,001, OR=2,51; 95% CI= 1,06-5,98; p=0,036 y OR=4,04; 95% CI =1,70-9,62; p=0,002, respectively) (Table 5).

4. Discussion

In our study, the prevalence of DGBI was 23.4%, a result consistent with that reported in a recent meta-analysis [14]. Consistent with current literature, the most frequently identified disorder was functional constipation, recognized as the most prevalent DGBI in pediatric population [15]. Regarding the overlap of DGBIs, our study identified a prevalence of 2.7%, which is lower than that reported in previous studies conducted in Latin American pediatric populations. In particular, one study [16] reported an overlap prevalence of 8.4% using the Rome III Criteria. This difference could be explained, at least in part, by the use of different diagnostic criteria, as the Rome IV Criteria used in our study are more restrictive and have been shown to identify a smaller proportion of cases compared with Rome III. Additionally, methodological variations—such as the characteristics of the questionnaire used, the operational definition of overlap, the age range of the studied population, and the sociocultural context—may have influenced the lower frequency of overlap observed.

The results of this study provide evidence that several DGBIs traditionally considered exclusive to the adult population according to the Rome IV Criteria can be identified in the pediatric age group, although with a relatively low prevalence (5.8%). This finding raises important questions regarding the current age-based delimitation of diagnostic criteria for DGBIs and suggests that a strict separation between pediatric and adult phenotypes may not fully reflect the physiopathological continuity of these disorders across the life course [17,18]. In contrast, population-based studies in adults have reported that up to 40.3% of the population presents at least one DGBI when the Rome IV Criteria are applied, reinforcing the hypothesis that these conditions may manifest early with subclinical or incomplete expressions during childhood and later consolidate or become more evident in subsequent stages of life [19].

The higher frequency observed in adolescents supports the hypothesis that the clinical expression of DGBIs evolves progressively with age, possibly influenced by neurobiological, hormonal, and psychosocial changes characteristic of this stage [17,20]. Previous studies have described that functional gastrointestinal symptoms in childhood may persist or evolve into more complex clinical presentations in adulthood, reinforcing the notion of a continuous spectrum rather than discrete entities [21,22,23]. Nevertheless, the lack of validated pediatric criteria for these disorders limits direct comparison with other studies and underscores the need for longitudinal research. The finding of proctalgia fugax as the most frequent adult DGBI in our pediatric cohort is noteworthy, as this functional anorectal disorder is usually underrepresented in pediatric epidemiological studies, likely due to difficulties in its identification in routine clinical practice and the underreporting of anorectal symptoms [24,25]. In the adult population, proctalgia fugax has been reported with a variable prevalence, ranging approximately from 8.0 to 18.0% in population-based studies, suggesting that it is a relatively common but underdiagnosed condition [26]. This discrepancy between the frequency reported in adults and its limited description in pediatrics reinforces the hypothesis that the use of structured questionnaires based on the Rome IV Criteria may have contributed to greater detection of these symptoms, highlighting the importance of standardized instruments for a more comprehensive characterization of the spectrum of DGBIs in the pediatric age group [27].

In our study, the prevalence of functional diarrhea was 0.9%, a figure lower than that reported among school-aged children and adolescents in other population-based studies, where a prevalence near 1.7% has been described [18]. This frequency contrasts more markedly with what has been observed in the adult population, in which functional diarrhea reaches significantly higher prevalences, estimated between 3.6% and 5.3% according to population-based studies using the Rome IV Criteria [28]. These differences suggest that the clinical expression of functional diarrhea may increase with age, either due to true progression of the disorder across development or to a greater ability of adults to recognize, report, and seek care for this type of symptom. Likewise, the fact that functional diarrhea is not formally included in the Rome IV Criteria for school-aged children and adolescents may contribute to its underdiagnosis in the pediatric population, reinforcing the hypothesis that this entity is part of a continuous spectrum of DGBIs that manifests differently across stages of the life course [29].

One of the most consistent findings was the independent association between depressive traits and school and social absenteeism with the presence of adult DGBIs according to the Rome IV Criteria in the pediatric population. From a critical perspective, these results challenge diagnostic models predominantly centered on gastrointestinal symptomatology, by showing that psychoemotional and functional determinants may play an equally or even more important role than somatic factors [24,30,31,32,33,34]. Depression, in particular, may act not only as an associated factor but also as a modulator of visceral perception thresholds and central pain processing, thereby contributing to symptom chronicity [33,34,35,36].

School and social absenteeism emerges as a key functional marker, likely reflecting both symptom severity and the impact of these disorders on the daily life of the child or adolescent [37]. Beyond being a consequence, absenteeism may constitute a perpetuating factor of the disorder by promoting social isolation, academic stress, and emotional deterioration, thereby creating a vicious cycle that hinders clinical recovery. This aspect has been scarcely explored in pediatric studies and warrants more systematic evaluation in future research.

Although quality of life showed a significant association in the bivariate analysis, its loss of significance in the multivariate model suggests that this outcome may be mediated by psychoemotional variables, particularly depression [33,38,39]. This finding reinforces the idea that the assessment of quality of life, while fundamental, should be interpreted within a broader framework that integrates the patient’s emotional state and social functioning [39,40].

This study has important limitations that should be acknowledged. Its cross-sectional design precludes the establishment of causal relationships and does not allow determination of whether depressive traits precede or result from gastrointestinal symptoms. Likewise, the use of self-reported questionnaires may introduce information bias, and the application of adult criteria to a pediatric population, although conceptually justified, still lacks formal validation. These limitations, however, do not invalidate the findings; rather, they reinforce their exploratory and hypothesis-generating nature.

Overall, the results of this study support a critical view of the current diagnostic approach to DGBIs in pediatrics and highlight the need to move toward more integrative and dimensional models. The systematic incorporation of psychoemotional and functional variables, along with the development of age-adapted diagnostic criteria, could improve early identification of these disorders and optimize clinical management strategies in children and adolescents.

5. Conclusions

According to the results obtained through the application of the adapted QPGS-IV questionnaire, the presence of various functional conditions was identified in the studied pediatric population. These findings highlight the importance of recognizing that, although these conditions are commonly associated with adults, they may also occur in children and can have a significant impact on their quality of life and development. In addition, the main factors associated with the presence of these conditions were depressive traits and school absenteeism, suggesting a potential interaction between psychosocial and emotional aspects and the emergence of functional symptoms in the pediatric population.

These results lead to the important consideration that diagnostic criteria and classifications, such as the Rome Criteria—currently focused on adults—could benefit from revision or adaptation to include these disorders in children, while recognizing their specificity at this stage of life. In addition, healthcare professionals are encouraged to consider not only pathophysiological aspects but also psychosocial and behavioral factors that may influence the onset and persistence of these symptoms. Integrating these components into clinical assessment would allow for a more comprehensive and effective approach, promoting more personalized therapeutic strategies and improving outcomes in pediatric care. In conclusion, these findings underscore the need to broaden the diagnostic approach toward a biopsychosocial perspective, taking into account the particularities of the pediatric and adolescent population to optimize clinical management and prevention.