Introduction

Functional dyspepsia (FD) is a common disorder in childhood. This disorder is associated with upper gastrointestinal symptoms, including epigastric pain or burning sensation, early satiety, and postprandial fullness, unrelated to bowel movements or other etiology to explain these symptoms. This disorder can cause a significant deterioration in the quality of life^1,2.

In recent years, FD’s prevalence has increased (3%-27%), with a high demand for consultation of pediatric specialties. In many cases, FD may be associated with other gastrointestinal functional disorders, one of the most common after irritable bowel syndrome. Approximately 4.5% of children worldwide experience symptoms of FD at some point in their lives^2,3.

Patients with functional gastrointestinal disorders (FGIDs), which include FD, have higher rates of anxiety, depression, poor coping skills, and somatization symptoms than children without FGIDs. Children with FD may be associated with significant morbidity, and symptoms may negatively impact the child’s quality of life, adversely affecting school attendance³.

Over time, FD diagnostic criteria have evolved. For the first time, the Rome IV criteria identified epigastric pain syndrome (EPS) and postprandial distress syndrome (PDS) as two subtypes of FD in children, as recognized in adults.^3-5

According to the Rome IV Criteria, no studies have demonstrated the prevalence of FD in Cuban children. Understanding the associated factors would be extremely useful for diagnosing and managing this disorder. Thus, this study aims to determine the prevalence of FD in Cuban adolescents and their possible associations.

Methodology

The study was conducted between March 2, 2020, and January 7, 2021, in 3 schools (2 primary schools and 1 basic secondary) in La Havana, Cuba. It was applied using the methodology in previous studies and those currently in progress by our group, Functional International Digestive Epidemiological Research Survey (FINDERS), an established international collaborative group that conducts epidemiological studies in Latin American children. Thus, parents or guardians of adolescents between fourth and ninth grades were invited and agreed to participate in the study after signing an informed consent/assent. We used the Questionnaire of Pediatric Gastrointestinal Symptoms-Rome IV Criteria (QPGS-IV) in Spanish, which has an appropriate criterion validity⁶. Sociodemographic (age, gender, race); personal (cesarean section, preterm birth); family (only child, firstborn, separated/divorced parents, intrafamily FGIDs); clinical (weight, height, body mass index [BMI], height-for-age, dengue history), and epidemiological (overlap, confinement) variables were obtained. The Hospital Dr. Luis Díaz Soto’s Ethics Committee approved this study. Statistical analysis included the student’s t-test two-sided, the Chi-Square test, and Fisher’s exact test. To evaluate the possible risk factors for DF, a univariate and multivariate analysis was performed, calculating the odds ratio (OR) with its corresponding 95% confidence intervals (CI) and a p significant < 0.05.

Results

From a group of 318 adolescents who answered the QPGS-IV in Spanish, 29.1% showed some FGID. We identified FD in 3.5% (2.2% postprandial distress syndrome -PDS, and 1.3% epigastric pain syndrome -EPS) (Table 1).

The 11 children with FD were 11.4 ± 1.2 years, 81.8% were female and 54.4% mestizo, 54.5% were firstborn, 72.7% had separated/divorced parents, and 63.6% and 100.0%, respectively, were eutrophic for BMI and height-for-age according to the World Health Organization (WHO). There was an overlap of FD in 8 of the 11 children, primarily with functional constipation in 7 children. There were no significant differences between the sociodemographic (age, gender, race); personal (cesarean section, preterm birth); family (only child, firstborn, separated/divorced parents, intrafamily FGIDs); clinical (weight, height, BMI, height-for-age, dengue history), and epidemiological (overlap, confinement) variables (Table 2).

The prevalence of FD was higher in females (OR: 5.33; 95%CI: 1.06-51.45; p = 0.019). The same was the case for children whose parents were separated/divorced (OR: 4.74; 95%CI: 1.09-28.31; p = 0.014), predominantly in paternal absence (OR: 3.64; 95%CI: 0.88-17.42; p = 0.033) rather than maternal absence. The multivariate analysis did not show any variable contributing to FD overlap prevalence (Table 3).

Discussion

As far as we know, this is the first study that evaluated the prevalence and factors associated with FD in Cuban children according to the Rome IV criteria. Findings in this research showed that 29.1% of adolescents met the criteria for some FGID, FD was identified in 3.5%, and PDS is more frequent than EPS.

Our results are similar to those reported by Saps et al⁷ in Colombian children, with a 3% FD prevalence, which is lower than the results reported by Robin et al⁸ in North American children and by Baleeman et al⁹ in Colombian children, between 7.2% and 16.1%, respectively, and higher than those reported by Zeevenhooven et al¹⁰ in adolescents from Curacao, whose prevalence for FD was 1.9%. One of the possible explanations for these different figures, among others, is how these interviews were conducted. The data from North American children⁸ were taken from the mothers’ self-responses. Conversely, Colombian children^7,9 completed the questionnaires through self-response, and the QPGS-III was applied to the children in Curaçao¹⁰, while the data interpretation to identify any FGID was conducted according to QPGS-IV.

On the other hand, other authors have only studied FD as part of FGIDs. Some of them^1,8,11, like us, have described a higher prevalence to present the PDS over the EPS subtype. Even Wei et al¹¹ found a 0.3% overlap between both FD subtypes, similar findings to ours with only 1 patient presenting such overlap, and different from the high prevalence reported by Turco et al¹. The latter found a 36.0% overlap between both FD subtypes, which suggests a common pathophysiological mechanism. However, it is worth noting that Turco et al¹ classified FD subtypes according to the QPGS-III for adults.

Our results show that FD occurred more in female adolescents, as described by Kumagai et al¹², but different from Wei et al¹¹ and Turco et al¹, who did not find this association. Other authors have described some possible factors for presenting FD like Wei et al¹¹ that found age (OR: 1.112; 95%CI: 1.031-1.201; p = 0.006) and independent living from parents (OR: 1.677; 95%CI: 1.255-2.242; p < 0.001) as possible causes to develop FD. In their study with Japanese children, Kumagai et al¹² associated FD prevalence with sleeping habits. Although many patients with FD associate their dyspeptic symptoms with eating habits, few studies show that dietary factors may be involved in developing this FGID. For example, Wei et al¹¹ describe that delayed school meals (OR: 2.107; 95%CI: 1.447-3.068; p < 0.001), skipping breakfast (OR: 2.192; 95%CI: 1.103-3.688; p = 0.003), eating frequently (OR: 2.296; 95%CI: 1.347-3.912; p = 0.002), and eating cold foods daily (OR: 2.736; 95%CI: 1.263-5.927; p = 0.011) are possible food-related risk factors leading to FD. Likewise, Kumagai et al¹² found that impaired eating habits constitute a risk factor for developing FD.

Another risk factor we found leading to develop FD is children from separated parents. According to the biopsychosocial model, we cannot ignore that psychosocial factors play a crucial role in the pathogenesis of FGIDs. Stress has pathophysiological effects on the gastrointestinal tract, triggering or exacerbating abdominal pain through visceral hypersensitivity and changes in motility. Children with depressive or anxious symptoms are more likely to develop FGIDs^1,5,12. Divorce is a major stressor at this age. Several Latin American studies associate the presence of separated/divorced parents with the prevalence of FGIDs ^13,14, consistent with this study. Wei et al¹¹ also identified that children living independently from their parents were at higher risk of developing FD, comparable to the separated parents in this study. These two factors may trigger anxiety and stress in these patients.

Thus, the main strength of our study is that it is the first cross-sectional study conducted on Cuban adolescents that determined the prevalence of FD and its associated factors. However, this study also has limitations since, like other studies using the Questionnaires of Pediatric Gastrointestinal Symptoms, Rome IV version, it includes failure to ensure external validity of the results since the symptoms depend on the adolescent’s report, which is based on the recollection of the event and its frequency, so there may be a memory bias. On the other hand, with the existing situation due to the 2019 coronavirus disease (COVID-19) and school closures, the series could not be larger and more representative.

In conclusion, functional dyspepsia is most common in female adolescents, PDS is the most frequent subtype, and its presence is associated with separated/divorced parents.