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    Rome IV Diagnostic Criteria for Infant Functional Diarrhea

    Official Rome IV criteria for the diagnosis of infant functional diarrhea.

    INSTRUCTIONS

    Use in otherwise healthy infants, toddlers and pre-school children with symptoms suggestive of functional diarrhea including daily painless diarrhea for at least 4 weeks. 

    Patients with any of the following alarm features should be evaluated clinically for other diagnoses:

    • Weight loss 
    • Failure to thrive
    • Abnormal growth
    • Abdominal pain or distension
    • Bloody stools
    • Respiratory symptoms
    • Abnormal perianal exam
    • Vomiting
    • Fever
    • Family history of celiac disease, pancreatitis, inflammatory bowel disease
    When to Use
    Pearls/Pitfalls
    Why Use

    Infants and pre-school children presenting with diarrhea who are otherwise growing and thriving normally. The diagnosis of functional diarrhea should be made by clinical history, positive symptom criteria and physical examination. Laboratory or imaging studies are typically not needed in the absence of any alarm features. 

    • Functional diarrhea occurs between the ages of 6 months and 5 years and resolves by school-age. It is the most common cause of chronic diarrhea in an otherwise healthy child.
    • Functional diarrhea is also referred to as toddler’s diarrhea or chronic nonspecific diarrhea.
    • Nutritional factors play an important role in the pathogenesis of functional diarrhea. A thorough dietary history is therefore important with specific inquiries about overfeeding, fructose (e.g. apple, prune or pear juice), sorbitol (often in “sugar-free” foods and beverages), and high osmolarity fluid intake and/or restriction of dietary fat. 
    • Except for reduction of fructose and sorbitol, and normalization of fat intake, other restrictive diets are typically not necessary and may unnecessarily result in calorie and nutrient restriction with weight-loss.
    • The pathophysiological understanding of functional diarrhea is based on the hypothesis that the small bowel absorptive capacity for certain carbohydrates is exceeded, resulting in osmotic diarrhea and colonic fermentation which in turn can lead to abdominal distension and passage of flatus. Small bowel transport, water and electrolyte secretion, glucose, and nutrient absorption are normal in functional diarrhea. 
    • Parents frequently report mucous and/or undigested food passed in the diarrheal stools, often foods that were eaten only a few hours prior. These findings have no clinical relevance.
    • Stools often become looser as the day progresses. 
    • Children are not disturbed by the diarrhea as it is not associated with any discomfort.
    • Other factors that can trigger or worsen chronic diarrhea in children should be considered including laxative use, constipation with incontinence, antibiotics, and recent enteric infections. 
    • While reassurance and dietary interventions constitute the main pillars of treatment, in children that do not respond to simple dietary interventions or screen positive for any alarm features (see above), further diagnostic evaluation may be indicated to evaluate for infections, allergies, celiac disease, cystic fibrosis, metabolic disease, and inflammatory bowel disease. 
    • Used to establish the diagnosis of infant diarrhea in otherwise healthy infants, toddlers, and pre-school age children who present with chronic diarrhea. 
    • Making a diagnosis will help provide anticipatory guidance and reassurance, allows for an early trial of dietary interventions while avoiding unnecessary doctor visits, testing, and excessive dietary restrictions.

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    Creator Insights
    Dr. Douglas Drossman

    About the Creator

    Douglas Drossman, MD, is professor emeritus of medicine and psychiatry at the University of North Carolina School of Medicine. He is founder, President Emeritus and Chief of Operations of the Rome Foundation. He is also the founder of the Drossman Center for the Education and Practice of Biopsychosocial Care and Drossman Consulting, LLC. Dr. Drossman has written over 500 articles and book chapters, has published two books, a GI procedure manual and a textbook of functional GI disorders (Rome I-IV), and serves on six editorial and advisory boards.

    To view Dr. Douglas Drossman's publications, visit PubMed

    Dr. Lin Chang

    About the Creator

    Lin Chang, MD is responsible for the oversight and coordination of the Rome IV calculators on MDCalc. She is a Professor of Medicine at the Vatche and Tamar Manoukian Division of Digestive Diseases at UCLA and is a member of the Rome Foundation Board of Directors.

    To view Dr. Lin Chang's publications, visit PubMed

    The Rome Foundation

    About the Creator

    The Rome Foundation is an independent not for profit 501(c) 3 organization that provides support for activities designed to create scientific data and educational information to assist in the diagnosis and treatment of Disorders of Gut-Brain Interaction (DGBI), also known as functional gastrointestinal (GI) disorders. Their mission is to improve the lives of people with DGBI. Over the last 3 decades, the Rome organization has sought to legitimize and update our knowledge of the DGBIs. This has been accomplished by bringing together scientists and clinicians from around the world to classify and critically appraise the science of GI function and dysfunction. This knowledge permits clinical scientists to make recommendations for diagnosis and treatment that can be applied in research and clinical practice. Diagnosis is based on the use of symptom-based criteria which are used in clinical trials and daily practice. The list of Rome IV categories and the Chair and Co-Chair of each chapter committee are listed below.

    Committees Chair Co-Chair
    Esophageal Disorders Ronnie Fass, MD John Pandolfino, MD
    Gastroduodenal Disorders Nicholas J. Talley, MD, PhD, FRACP Vincenzo Stanghellini, MD
    Bowel Disorders Fermin Mearin, MD Brian Lacy, MD, PhD
    Gallbladder and Sphincter of Oddi Disorders Grace Elta, MD Peter Cotton, MD
    Centrally Mediated Disorders of Gastrointestinal Pain Peter J. Whorwell, MD Laurie Keefer, PhD
    Anorectal Disorders Adil E. Bharucha, MD, MBBS Satish S. C. Rao, MD, PhD, FRCP
    Childhood Functional Gastrointestinal Disorders: Neonate/Toddler Sam Nurko, MD Marc A. Benninga, MD
    Childhood Functional Gastrointestinal Disorders: Child/Adolescent Carlo Di Lorenzo, MD Jeffrey S. Hyams, MD

    Rome IV Diagnostic Criteria Chapters, Chairs and Co-Chairs

    Rome IV Editorial Board: Douglas A. Drossman, MD, Senior Editor, Lin Chang, MD, William D. Chey, MD, John Kellow, MD, Jan Tack, MD, PhD, and William E. Whitehead, PhD.

    To view The Rome Foundation's publications, visit PubMed

    Content Contributors
    • Beate Beinvogl, MD, MPH
    Reviewed By
    • Samuel Nurko, MD, MPH
    About the Creator
    Dr. Douglas Drossman
    Dr. Lin Chang
    The Rome Foundation
    Content Contributors
    • Beate Beinvogl, MD, MPH
    Reviewed By
    • Samuel Nurko, MD, MPH