APPENDIX 1.

Summary of the Quality of the Evidence

QuestionEvidenceQuality of Evidence
1There is limited but credible evidence of the existence of functional dyspepsia, IBS, and abdominal migraine in children.C
2There are no studies of unselected patients showing that pain frequency, severity, location, or effects on lifestyle are able to distinguish between functional and organic disorders.C
2Children with recurrent abdominal pain are more likely than children without recurrent abdominal pain to have headache, joint pain, anorexia, vomiting, nausea, excessive gas, and altered bowel symptoms. There are insufficient data to determine whether the presence of associated symptoms can help the physician to distinguish between functional and organic disorders.C
2The presence of alarm symptoms or signs suggests a higher pretest probability or prevalence of organic disease and may justify the performance of diagnostic tests. Alarm symptoms or signs include but are not limited to involuntary weight loss, deceleration of linear growth, gastrointestinal blood loss, significant vomiting, chronic severe diarrhea, persistent right upper or right lower quadrant pain, unexplained fever, and family history of inflammatory bowel disease.D
3There is no evidence to evaluate the predictive value of blood tests.D
3There is no evidence to determine the predictive value of blood tests in the face of alarm signals.D
4There is no evidence to suggest that the use of ultrasonographic examination of the abdomen and pelvis in the absence of alarm symptoms has a significant yield of organic disease.C
4There is little evidence to suggest that the use of endoscopy and biopsy in the absence of alarm symptoms has a significant yield of organic disease.C
4There is insufficient evidence to suggest that the use of esophageal pH monitoring in the absence of alarm symptoms has a significant yield of organic disease.C
5There is a small amount of evidence suggesting that the presence of recent negative life events is not useful in distinguishing between functional abdominal pain and abdominal pain of other causes.B
5There is limited evidence suggesting that daily stressors are associated with the occurrence of pain episodes and that higher levels of negative life events are associated with increased likelihood of symptom persistence.C
5There is no evidence on whether life stress influences symptom severity, course, or response to treatment.D
5There is evidence suggesting that the presence of anxiety, depression, or behavior problems is not useful in distinguishing between functional abdominal pain and abdominal pain of other causes.B
5There is evidence that patients with recurrent abdominal pain have more symptoms of anxiety and depression (internalizing emotional symptoms) than do healthy community controls.B
5In contrast, there is evidence that children with recurrent abdominal pain do not have higher levels of conduct disorder and oppositional behavior (externalizing emotional symptoms) compared with healthy community controls.B
5There are no data on whether emotional/behavioral symptoms predict symptom severity, course, or response to treatment.D
5There is evidence suggesting that children with recurrent abdominal pain are at risk of later emotional symptoms and psychiatric disorders.B
5There is evidence that parents of patients with recurrent abdominal pain have more symptoms of anxiety, depression, and somatization than do parents of community controls or parents of other pediatric patients.C
5There is some evidence that families of patients with recurrent abdominal pain do not differ from families of community controls or families of patients with acute illness in broad areas of family functioning, such as family cohesion, conflict, and marital satisfaction.C
6There is evidence that treatment for 2 wk with peppermint oil may provide benefit in children with IBS.B
6There is inconclusive evidence of the benefit of H2 blockers to treat children with dyspepsia.B
6There is inconclusive evidence that fiber supplement intake decreases the frequency of pain attacks for patients with recurrent abdominal pain.B
6There is inconclusive evidence that a lactose-free diet decreases symptoms in children with recurrent abdominal pain.B
6There are limited data to suggest that pizotifen is efficacious in the treatment of abdominal migraine.B
7There is evidence that cognitive-behavioral therapy may be useful in improving pain and disability outcome in the short term.B
8There is no evidence of the possible beneficial role of surgery in the evaluation or management of children with recurrent abdominal pain.D
8There are no studies comparing diagnostic or therapeutic surgery with other approaches.D