ESPGHAN/NASPGHAN guidelines for treatment of [IBS] and functional abdominal pain-not otherwise specified in children aged 4–18 year 2025 Groen et al

[Andy]

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.

Highlights
What is known

• AP-DGBIs like IBS and FAP-NOS share overlapping mechanisms and are often studied together in pediatric trials.
  
  
• Clinical treatment practices vary regionally and include numerous options, many lacking strong pediatric data.
  

What is new

• Gut-brain psychotherapies, especially hypnotherapy, show the strongest evidence and effect size.
  
  
• Common treatments like anticholinergics, bile acid sequestrants, and loperamide lack pediatric evidence.
  

Open access

 

[Andy]

"Executive summary of recommendations with at least low certainty evidence

• Hypnotherapy is recommended as a treatment option
  • (Strong recommendation, Moderate certainty evidence)
    
• Cognitive Behavioral therapy (CBT) is recommended as a treatment option
  • (Strong recommendation, Low certainty evidence)
    
• Percutaneous Electrical Nerve Field Stimulation (PENFS) is suggested as a treatment option
  • (Conditional recommendation, Moderate certainty evidence)
    
• Probiotics (Multi-strain) and Synbiotics (multi-strain probiotics and prebiotic) may be suggested as a treatment option
  • (Conditional recommendation, Low certainty evidence)
    
• Enteric-coated peppermint capsules may be suggested as a treatment option
  • (Conditional recommendation, Low certainty evidence)
    
• Amitriptyline may be suggested as a treatment option
  • (Conditional recommendation, Low certainty evidence)
    
• Domperidone may be suggested as a treatment option
  • (Conditional recommendation, Low certainty evidence)
    
• Cyproheptadine may be suggested as a treatment option
  • (Conditional recommendation, Low certainty evidence)
    
• Buspirone is NOT suggested as a treatment option
  • (Conditional recommendation, Low certainty evidence)
    
• Mebeverine is NOT suggested as a treatment option
  • (Conditional recommendation, Low certainty evidence)
    
• Drotaverine is NOT suggested as a treatment option
  • (Conditional recommendation, Low certainty evidence)
    
• Citalopram is NOT suggested as a treatment option
  • (Conditional recommendation, Low certainty evidence)
    
• Yoga is NOT suggested as a treatment option
  • (Conditional recommendation, Low certainty evidence)
    
  
  Irritable Bowel Syndrome (IBS) Specific recommendations
• 
  
• Soluble dietary fiber supplements (i.e., hydrolized guar gum, glucomannan, psyllium) are suggested as a treatment option for IBS only
  • (Conditional recommendation, Moderate certainty evidence)
    
• Lactobacillus rhamnosus GG is suggested as a treatment option for IBS
  • (Conditional recommendation, Moderate certainty evidence) (Figures 1 and 2)"

 

[Jonathan Edwards]

ESPGHAN, NASPGHAN

The existence of two organisations with the same initial structure strongly suggests that they have been set up by a common political motivation. That seems to be borne out by the review content.

 

[Utsikt]

This document outlines the recommendations of the joint ESPGHAN/NASPGHAN GDG. The development process was guided by the GRADE framework, as outlined in the GRADE handbook, supported by the World Health Organization (WHO).15 In line with this guidance, a complete protocol for the technical review, along with associated operating procedures, was agreed upon in advance and published previously,16 in line with other similar guidelines.17

The GDG was chaired by a member of each of the societies (for ESPGHAN, M.B., for NASPGHAN, A.D.), as well as a GRADE methodologist, pediatrician, and Editor of the Cochrane Gut group (M.G.). Wider GDG members were chosen as experts in AP-DGBI management, and to ensure a wide range of clinical expertise. The 15 voting members included a general pediatrician (A.V.), pediatric gastroenterologists (M.B., R.B., O.B., A.C., A.D., J.D., J.K., C.D.L., H.P., R.S., N.T., M.T., and M.S.), a pediatric psychiatrist (H.P.), and a clinical psychologist (J.S.). A nonvoting methodological team comprised the GRADE co-chair (M.G.) and two members (J.G. and V.S.), who were primarily responsible for technical systematic review and GRADE analysis of data and data synthesis summaries. One of the methodological team members (V.S.) is also a registered dietitian.

2.8 Certainty of the evidence
Risk of bias was assessed using the Cochrane risk-of-bias tool for RCTs and certainty of the evidence was assessed using the GRADE approach.24 Since we only used the adapted COS (Table 1), indirectness of reported outcomes was not considered an issue and rated as “not serious” by default. Publication bias had been addressed through our search strategy, with insufficient study numbers to allow funnel plot use and therefore was also judged as “not serious” by default.

I don’t understand how you can rate something as «not serious» when you’re unable to assess it. Surely that should lower the quality of the evidence.

They also went on to make recommendations for e.g. hypnotherapy even though there were significant issues with e.g. blinding.

I’m not confident they understand basic research methodology based on this paper.

 

[Sean]

• Hypnotherapy is recommended as a treatment option
  • (Strong recommendation, Moderate certainty evidence)

• Cognitive Behavioral therapy (CBT) is recommended as a treatment option
  • (Strong recommendation, Low certainty evidence)

In what universe is this even internally consistent?

 

[rvallee]

Gut-brain psychotherapies, especially hypnotherapy, show the strongest evidence and effect size.

The medical profession struggles massively with the fact that the best they can do does not mean that it's any good. In fact this is atrocious. Even most random amateurs would do better than this. It takes serious talent and dedication to be this bad at anything. As a housing comparison, this is a hole in the ground. A small damp hole with sharp rocks.

But even more problematic is that when your methods give you as "strongest evidence and effect size" "especially hypnotherapy", you don't have actual methods, you have a completely dysfunctional mess of a system. I don't see how any serious person can have anything but contempt for this trash.

Put another way, this is the equivalent of if generative AI had stopped well before it got there, and they tried selling it as a consumer product anyway. This resembles Will Smith eating spaghetti far more than this trash resembles science or the work expected of serious professionals.