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. 2025 Aug 25;20(3):427–438. doi: 10.5009/gnl250225

Global Prevalence of Functional Abdominal Pain Disorder among Children and Adolescents According to the Rome III and IV Criteria: A Systematic Review and Meta-Analysis

Yi Deun Jeong 1,2,#, Soeun Kim 2,3,#, Yejun Son 2,3, Tae Hyeon Kim 1,2,3, Lee Smith 4,5, André Hajek 6, Jiseung Kang 7,8, Jong Woo Hahn 9,10,✉, Dong Keon Yon 1,2,3,11,✉
PMCID: PMC13180508  PMID: 40852741

Abstract

Background/Aims

Despite the global burden of functional abdominal pain disorder (FAPD) and its four subtypes (irritable bowel syndrome [IBS], functional dyspepsia [FD], abdominal migraine [AM], and functional abdominal pain not otherwise specified [FAP-NOS]), studies involving an estimation of FAPD prevalence based on the Rome III or IV criteria are limited. Therefore, we aimed to estimate the prevalence of FAPD and its four subtypes.

Methods

A comprehensive literature search was conducted in PubMed/MEDLINE, Embase, Google Scholar, and the Cochrane Library. Studies that were performed with the general population and applied Rome III or IV diagnostic criteria were included. Data were extracted to estimate the prevalence of FAPD using a random-effects model with 95% confidence intervals (CIs). Heterogeneity was assessed using the I2 statistic. The study protocol was preregistered with PROSPERO (CRD420251004116).

Results

The overall prevalence of FAPD was 10.89% (95% CI, 9.51% to 12.48%), with pooled prevalence rates of 11.84% (10.29% to 13.61%) with the Rome III criteria and 8.42% (6.10% to 11.62%) with the Rome IV criteria. With the Rome III criteria, IBS had the highest prevalence, while FD had the lowest. In contrast, with the Rome IV criteria, the prevalence of IBS, AM, and FAP-NOS decreased, whereas FD became the most prevalent, affecting approximately one in 23 individuals, compared to one in 51 individuals affected by IBS, one in 68 individuals affected by AM, and one in 115 individuals affected by FAP-NOS. Additionally, females exhibited higher prevalence rates of FAPD and all its subtypes than males.

Conclusions

The diagnostic criteria of Rome IV are stricter than those of Rome III, which likely affects the estimated prevalence of FAPD and its subtypes.

Keywords: Adolescents, Child, Functional gastrointestinal disorders, Meta-analysis, Prevalence

INTRODUCTION

Functional abdominal pain disorder (FAPD) is a type of childhood functional gastrointestinal disorder (FGID) that includes irritable bowel syndrome (IBS), functional dyspepsia (FD), abdominal migraine (AM), and functional abdominal pain not otherwise specified (FAP-NOS), as defined by the Rome IV criteria.1 While the etiology of FAPD is primarily attributed to disorders of gut-brain interaction, its epidemiology varies across different demographic and geographic populations.2 Moreover, FAPD is associated with a reduced quality of life,3 increased levels of anxiety and depression compared to healthy individuals,4 and a greater economic burden due to the substantial utilization of healthcare resources.5,6

Previous research on FGID has primarily focused on adult populations.7-9 Studies on the prevalence of these disorders in children and adolescents remain limited and are often restricted to specific regions.10 Furthermore, no study has specifically investigated the prevalence of FAPD independently from broader FGID research, with only a single meta-analysis on FAPD published a decade ago.11 However, this meta-analysis also has limitations in accurately estimating the epidemiological characteristics of FAPD due to the heterogeneity in classification criteria.11

FAPD remains a significant global health burden due to the limited understanding of its etiology and availability of treatment options.12 Therefore, this study aimed to estimate the global prevalence of FAPD and its subtypes based on the Rome III and Rome IV criteria, highlighting the importance of distinguishing between these criteria to examine potential differences in prevalence trends. Additionally, this study investigated variations in prevalence according to demographic factors and geographical regions. By providing a comprehensive epidemiological assessment, this study seeks to contribute to a better understanding of FAPD and support efforts to address its global burden.

MATERIALS AND METHODS

1. Search strategy and selection criteria

This systematic review and meta-analysis were conducted to estimate the prevalence of FAPD and its subtypes. The study protocol was preregistered in the PROSPERO database (CRD420251004116), and the manuscript was prepared in accordance with the PRISMA 2020 statement (Supplementary Table 1).13

A comprehensive literature search was performed in PubMed/MEDLINE, Embase, Google Scholar, and the Cochrane Library from Jan 1, 2006, to August 9, 2024, as the Rome III criteria were introduced in 2006 and the Rome IV criteria in 2016, ensuring the inclusion of relevant studies published after the establishment of those diagnostic frameworks. The search strategy included the following keywords: (pediatric) AND ((irritable bowel syndrome) OR (colonic diseases, functional) OR (functional adj5 bowel) OR (functional dyspepsia) OR (abdominal migraine) OR (functional abdominal pain) OR (IBS)) AND ((incidence) OR (prevalence) OR (trend)). No additional restrictions were applied.

Studies were included if they reported prevalence rates of FAPD and its subtypes based on nationally representative or subnational populations. Articles published in foreign languages were translated for data extraction. Exclusion criteria included studies that were not based on the general population, those with duplicate populations already analyzed in another study, and studies that did not clearly specify the diagnostic criteria. Additionally, studies using diagnostic frameworks other than Rome III or IV (e.g., International Classification of Diseases code-based classifications, Apley and Naish criteria, Rome I, or Rome II) were excluded. Furthermore, studies involving participants such as individuals receiving health checkups at departments other than primary healthcare centers (e.g., gastroenterology clinics), individuals with specific occupations, or university students from particular academic departments were excluded. Studies with fewer than 50 participants were also excluded. Finally, studies lacking extractable prevalence or incidence data for FAPD and those that could not be retrieved were also excluded.

2. Data extraction and quality assessment

A total of 3,910 studies were initially screened, including 2,415 from PubMed/MEDLINE, 1,303 from Embase, 131 from Cochrane, and 61 from Google Scholar. Titles and abstracts were then independently reviewed by two researchers (Y.D.J. and S.K.) to identify studies meeting the eligibility criteria for data extraction. Any discrepancies were resolved through discussion with two additional authors (J.W.H. and Y.D.K.). Data extraction was independently conducted using Microsoft Excel (version 2020; Microsoft, Redmond, WA, USA). Following the initial screening, 191 studies met the eligibility criteria and were considered for further evaluation. Of these, 67 studies ultimately met the inclusion criteria for this meta-analysis. The data extraction process is illustrated in Supplementary Fig. 1.

The following information was extracted from each included study: study characteristics (first author, year, and country), patient identification methods, diagnostic criteria (categorized as defined as per or approximated Rome III or IV), questionnaire administration methods, study design (retrospective, cross-sectional, or prospective), demographic factors (age and sex), total sample size, and the number of patients with FAPD and its subtypes (IBS, FD, AM, and FAP-NOS). For studies reporting data based on both Rome III and Rome IV criteria, prevalence estimates were extracted separately for each diagnostic framework. Studies that strictly adhered to the published Rome III or IV criteria were classified as “defined as per Rome.”12,14 In contrast, studies utilizing modified but Rome-aligned questionnaires, such as Questionnaire of Pediatric Gastrointestinal Symptoms for Rome III, Questionnaire of Pediatric Gastrointestinal Symptoms for Rome IV, and Questionnaire on Pediatric Gastrointestinal Disorders for Rome IV, were categorized as “approximated.”

All studies were assessed for risk of bias (RoB) using the criteria developed by Hoy et al.15 Each study was evaluated based on nine items and classified as having a high, medium, or low RoB according to the overall quality of study design, methodology, and reporting. A study was considered to have a low RoB if three or fewer items were relevant and a high RoB if seven or more items were applicable. Details of the RoB assessment for prevalence studies are provided in Supplementary Table 2.

3. Data analysis

A comprehensive subgroup analysis was performed based on various factors, including demographic and geographic factors, diagnostic methods, questionnaire administration approaches, and disease type. IBS was classified into subtypes based on the predominant stool pattern: IBS with constipation (IBS-C), IBS with diarrhea (IBS-D), IBS with mixed bowel habits (IBS-M), and IBS unclassified (IBS-U). FD was divided into two subtypes: epigastric pain syndrome and postprandial distress syndrome. A random-effects model was applied to aggregate the proportions of patients with FAPD across the included studies, enabling prevalence estimates at the global, regional, and country levels. Bayesian methods were employed to generate a 95% prediction interval, offering insights into the robustness and potential variability of the findings. Heterogeneity among studies was quantified using the I2 statistic, with higher values indicating greater variability.16 A log-transformed scale was used in the meta-analysis to address sparse data. Publication bias was assessed through Egger’s test and funnel plots,17 with results provided in the Appendix. All statistical analyses were performed using Microsoft Excel and R software (Version 4.3.3; R Foundation, Vienna, Austria). Statistical significance was defined as a two-sided p-value <0.05.18

RESULTS

1. Overall analysis

This meta-analysis included a total of 67 studies, encompassing 82 distinct populations, totaling 1,712,737 individuals from 34 countries, reporting diagnoses related to FAPD. The studies extracted and analyzed in this research are detailed in Supplementary Table 3. Among them, 51 studies reported the full spectrum of FAPD, 15 studies focused exclusively on the prevalence of IBS, and one study reported prevalence rates for both IBS and FD. Of these, 42 studies provided exact prevalence estimates for FAPD. Notably, two studies reported both abdominal pain-FGID and FAPD prevalence based on both Rome III and Rome IV criteria. In contrast, nine studies described the spectrum of FAPD without reporting an overall prevalence, leading to their exclusion from the FAPD prevalence estimation due to the overlapping nature of FAPD subtypes.

Specifically, 33 studies reported abdominal pain-FGID (equivalent to FAPD under Rome IV),19-51 10 studies provided prevalence based on Rome III definitions,20,23,26,29,30,34,40,41,43,50 and 23 studies approximated Rome III criteria.19,21,22,24,25,27,28,31-33,35-39,42,44-49,51 Regarding data collection methods, 30 studies utilized patient- or parent-reported questionnaires,19-22,24-28,30-38,40-42,44-51 while three studies were based on interviews.23,29,43 For FAPD specifically, 10 studies provided prevalence estimates,48,52-60 of which three studies adhered strictly to Rome IV definitions,54,57,59 and seven studies approximated Rome IV criteria.48,52,53,55,56,58,60 Additionally, eight studies collected data via patient- or parent-reported questionnaires,48,52,53,55-58,60 while two studies relied on interviews.54,59

2. Prevalence of FAPD and its sub-analyses

The overall estimated prevalence of FAPD diagnosed by Rome III and IV criteria is 10.89% (95% confidence interval [CI], 9.51% to 12.48%; I2=95.90%). Specifically, the estimated prevalence of FAPD was 11.84% (95% CI, 10.29% to 13.61%; I2=95.66%) based on Rome III criteria and 8.42% (95% CI, 6.10% to 11.62%; I2=95.92%) based on Rome IV criteria. The estimated prevalence among males was 8.55% (95% CI, 6.25% to 11.71%; I2=96.01%), while females had an estimated prevalence of 12.07% (95% CI, 10.22% to 14.26%; I2=89.69%) across both Rome III and IV criteria (Table 1). The overall prevalence at the country and regional levels according to Rome III and Rome IV criteria is presented in Fig. 1 and Supplementary Tables 4-5.

Table 1.

Global Pooled Prevalence of Pediatric FAPD and Its Subgroups (IBS, FD, AM, and FAPD-NOS) by Sex and Diagnostic Criteria: A Systematic Review and Meta-Analysis

No. of
studies		 No. of
participants		 Pooled estimates
(95% CI)* 		95% Prediction interval I2 (%) p-value
for I2 		Egger’s
p-value
FAPD 42 43,977 10.89 (9.51–12.48) 4.90–22.46 95.90 <0.001 0.086
Sex
Male 14 10,467 8.55 (6.25–11.71) 2.50–25.40 96.01 <0.001 0.157
Female 14 10,820 12.07 (10.22–14.26) 6.67–20.86 89.69 <0.001 0.264
Diagnosis criteria
Rome III 33 37,7791 11.84 (10.29–13.61) 5.60–23.33 95.66 <0.001 0.395
Rome IV 10 10,676 8.42 (6.10–11.62) 2.72–23.21 95.92 <0.001 0.256
IBS 67 1,715,601 4.37 (2.86–6.67) 0.10–67.88 99.81 <0.001 <0.001
Sex
Male 27 963,631 5.62 (2.53–12.45) 0.07–83.06 99.82 <0.001 0.001
Female 28 701,695 7.65 (3.49–16.78) 0.10–87.54 99.87 <0.001 <0.001
Diagnosis criteria
Rome III 54 86,041 6.12 (5.04–7.42) 1.40–23.00 98.49 <0.001 <0.001
Rome IV 15 1,638,143 1.95 (0.91–4.17) 0.05–43.66 99.41 <0.001 0.007
FD 49 70,911 1.59 (1.25–2.03) 0.26–8.98 95.19 <0.001 <0.001
Sex
Male 14 10,754 1.43 (0.72–2.83) 0.10–17.76 95.26 <0.001 0.004
Female 14 11,272 2.64 (1.77–3.93) 0.57–11.30 91.93 <0.001 0.013
Diagnosis criteria
Rome III 38 59,528 1.08 (0.79–1.48) 0.15–7.58 95.01 <0.001 <0.001
Rome IV 13 15,805 4.33 (3.21–5.83) 1.21–14.32 93.31 <0.001 0.311
AM 43 63,891 2.55 (2.02–3.21) 0.48–12.43 96.48 <0.001 <0.001
Sex
Male 11 7,588 1.64 (0.88–3.06) 0.16–14.43 90.63 <0.001 0.055
Female 11 8,067 3.96 (2.36–6.63) 0.56–23.24 95.12 <0.001 0.153
Diagnosis criteria
Rome III 34 52,834 3.16 (2.41–4.15) 0.56–15.93 97.81 <0.001 <0.001
Rome IV 10 15,479 1.48 (0.82–2.68) 0.13–15.21 95.54 <0.001 0.001
FAPD-NOS 49 68,368 1.91 (1.53–2.37) 0.39–8.83 95.03 <0.001 <0.001
Sex
Male 12 9,050 3.57 (2.70–4.72) 1.38–8.95 83.07 <0.001 0.072
Female 12 9,554 4.49 (3.31–6.08) 1.50–12.69 90.49 <0.001 0.045
Diagnosis criteria
Rome III 39 70,002 2.30 (1.78–2.96) 0.41–11.78 96.45 <0.001 0.001
Rome IV 12 15,893 0.87 (0.57–1.31) 0.19–3.98 84.28 <0.001 <0.001
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FAPD, functional abdominal pain disorders; IBS, Irritable bowel syndrome; FD, functional dyspepsia; AM, abdominal migraine; FAPD-NOS, FAPD not otherwise specified; CI, confidence intervals.

*Calculated and estimated from the original data provided in the study.

Fig. 1.

Fig. 1

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Global prevalence of FAPD, 2006 to 2024. Pooled estimates, % for prevalence. This world map was generated using the R software (Version 4.3.3). FAPD, functional abdominal pain disorders; NA, not available.

In sub-analyses, the estimated prevalence of FAPD was 13.56% (95% CI, 10.02% to 18.34%; I2=96.81%) based on strict Rome III criteria and 11.23% (95% CI, 9.72% to 12.98%; I2=94.00%) based on approximated Rome III criteria. When stratified by methods of questionnaire administration, the prevalence was 11.43% (95% CI, 10.01% to 13.04%; I2=94.83%) for studies using self- or parent-reported questionnaires and 18.20% (95% CI, 10.44% to 31.74%; I2=92.14%) for studies utilizing interviews (Supplementary Table 4). For analyses based on Rome IV criteria, the estimated prevalence was 8.23% (95% CI, 4.11% to 16.47%; I2=96.44%) for studies strictly adhering to Rome IV definitions and 8.48% (95% CI, 5.48% to 13.11%; I2=95.80%) for studies using approximated Rome IV definitions. Similarly, when stratified by methods of questionnaire administration, the estimated prevalence was 8.21% (95% CI, 5.54% to 12.16%; I2=95.07%) for studies using self- or parent-reported questionnaires and 9.04% (95% CI, 3.63% to 22.51%; I2=97.83%) for studies based on interviews (Supplementary Table 4).

3. Prevalence of IBS and its sub-analyses

The overall estimated prevalence of IBS diagnosed by Rome III and IV criteria is 4.37% (95% CI, 2.86% to 6.67%; I2=99.81%). Specifically, the estimated prevalence of IBS was 6.12% (95% CI, 5.04% to 7.42%; I2=98.49%) based on Rome III criteria and 1.95% (95% CI, 0.91% to 4.17%; I2=99.41%) based on Rome IV criteria. The estimated prevalence among males was 5.62% (95% CI, 2.53% to 12.45%; I2=99.82%), while females had an estimated prevalence of 7.65% (95% CI, 3.49% to 16.78%; I2=99.87%) across both Rome III and IV criteria (Table 1). The overall prevalence at the country and regional levels according to Rome III and Rome IV criteria is presented in Fig. 2 and Supplementary Tables 6-8.

Fig. 2.

Fig. 2

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Global prevalence of IBS, 2006 to 2024. Pooled estimates, % for prevalence. This world map was generated using the R software (Version 4.3.3). IBS, irritable bowel syndrome; NA, not available.

Although Rome III did not specifically classify IBS into subtypes, the estimated prevalence rates under Rome III were as follows: IBS-C: 2.66% (95% CI, 1.72% to 4.11%; I2=95.73%), IBS-D: 3.10% (95% CI, 1.87% to 5.12%; I2=97.54%), IBS-M: 2.54% (95% CI, 1.62% to 3.99%; I2=95.97%), and IBS-U: 1.75% (95% CI, 0.97% to 3.19%; I2=95.12%). Under Rome IV criteria, the estimated prevalence rates were IBS-C: 0.58% (95% CI, 0.25% to 1.36%; I2=81.35%), IBS-D: 0.28% (95% CI, 0.05% to 1.44%; I2=85.64%), IBS-M: 0.80% (95% CI, 0.22% to 2.90%; I2=88.79%), and IBS-U: 0.48% (95% CI, 0.15% to 1.57%; I2=91.42%).

In sub-analyses, the estimated prevalence of IBS was 7.33% (95% CI, 5.47% to 9.82%; I2=98.29%) based on strict Rome III criteria and 5.66% (95% CI, 4.41% to 7.25%; I2=98.42%) based on approximated Rome III criteria. When stratified by methods of questionnaire administration, the prevalence was 5.76% (95% CI, 4.73% to 7.01%; I2=98.40%) for studies using self- or parent-reported questionnaires and 10.71% (95% CI, 4.72% to 24.28%; I2=99.01%) for studies utilizing interviews (Supplementary Table 6). Additionally, in further sub-analyses, the estimated prevalence was 1.39% (95% CI, 0.52% to 3.70%; I2=99.35%) based on strict Rome IV criteria and 3.56% (95% CI, 1.74% to 7.31%; I2=96.50%) based on approximated Rome IV criteria. When stratified by methods of questionnaire administration, the prevalence was 2.16% (95% CI, 1.30% to 3.59%; I2=94.97%) for studies using self- or parent-reported questionnaires and 1.70% (95% CI, 0.21% to 13.66%; I2=99.86%) for studies utilizing interviews (Supplementary Table 6).

4. Prevalence of FD and its sub-analyses

The overall estimated prevalence of FD diagnosed by Rome III and IV criteria is 1.59% (95% CI, 1.25% to 2.03%; I2=95.19%). Specifically, the estimated prevalence of FD was 1.08% (95% CI, 0.79% to 1.48%; I2=95.01%) based on Rome III criteria and 4.33% (95% CI, 3.21% to 5.83%; I2=93.31%) based on Rome IV criteria. The estimated prevalence among males was 1.43% (95% CI, 0.72% to 2.83%; I2=95.26%), while females had an estimated prevalence of 2.64% (95% CI, 1.77% to 3.93%; I2=91.93%) across both Rome III and IV criteria (Table 1). The overall prevalence at country and regional levels according to Rome III and Rome IV criteria is presented in Fig. 3 and Supplementary Tables 9-10. Under Rome IV criteria, the estimated prevalence was 1.01% (95% CI, 0.59% to 1.75%; I2=87.19%) for FD-epigastric syndrome and 3.59% (95% CI, 2.48% to 5.18%; I2=92.52%) for FD-postprandial distress syndrome.

Fig. 3.

Fig. 3

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Global prevalence of FD, 2006 to 2024. Pooled estimates, % for prevalence. This world map was generated using the R software (Version 4.3.3). FD, functional dyspepsia; NA, not available.

In sub-analyses, the estimated prevalence of FD was 1.74% (95% CI, 0.94% to 3.21%; I2=94.95%) based on strict Rome III criteria and 0.92% (95% CI, 0.63% to 1.33%; I2=95.17%) based on approximated Rome III criteria. When stratified by methods of questionnaire administration, the prevalence was 1.03% (95% CI, 0.76% to 1.40%; I2=94.40%) for studies using self- or parent-reported questionnaires and 2.30% (95% CI, 0.25% to 20.86%; I2=98.57%) for studies utilizing interviews (Supplementary Table 9). For analyses based on Rome IV criteria, the estimated prevalence was 4.15% (95% CI, 2.71% to 6.36%; I2=93.91%) for studies strictly adhering to Rome IV definitions and 4.56% (95% CI, 2.89% to 7.20%; I2=93.31%) for studies using approximated Rome IV definitions. Similarly, when stratified by methods of questionnaire administration, the estimated prevalence was 4.59% (95% CI, 3.35% to 6.29%; I2=92.94%) for studies using self- or parent-reported questionnaires and 2.83% (95% CI, 1.92% to 4.19%; I2=72.04%) for studies based on interviews (Supplementary Table 9).

5. Prevalence of AM and its sub-analyses

The overall estimated prevalence of AM diagnosed by Rome III and IV criteria is 2.55% (95% CI, 2.02% to 3.21%; I2=96.48%). The estimated prevalence of AM was 3.16% (95% CI, 2.41% to 4.15%; I2=97.81%) based on Rome III criteria and 1.48% (95% CI, 0.82% to 2.68%; I2=95.54%) based on Rome IV criteria. The estimated prevalence among males was 1.64% (95% CI, 0.88% to 3.06%; I2=90.63%), while females had an estimated prevalence of 3.96% (95% CI, 2.36% to 6.63%; I2=95.12%) across both Rome III and IV criteria (Table 1). The overall prevalence at country and regional levels according to Rome III and Rome IV criteria is presented in Fig. 4 and Supplementary Tables 11-12.

Fig. 4.

Fig. 4

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Global prevalence of AM, 2006 to 2024. Pooled estimates, % for prevalence. This world map was generated using the R software (Version 4.3.3). AM, abdominal migraine; NA, not available.

In sub-analyses, the estimated prevalence of AM was 2.55% (95% CI, 1.18% to 5.51%; I2=98.42%) based on strict Rome III criteria and 3.38% (95% CI, 2.57% to 4.43%; I2=96.68%) based on approximated Rome III criteria. When stratified by methods of questionnaire administration, the prevalence was 3.20% (95% CI, 2.44% to 4.21%; I2=97.72%) for studies using self- or parent-reported questionnaires and 2.50% (95% CI, 1.12% to 5.58%; I2=75.51%) for studies utilizing interviews (Supplementary Table 11). Additionally, in further sub-analyses, the estimated prevalence was 1.39% (95% CI, 0.73% to 2.68%; I2=92.36%) based on strict Rome IV criteria and 1.64% (95% CI, 0.50% to 5.43%; I2=97.56%) based on approximated Rome IV criteria. When stratified by methods of questionnaire administration, the prevalence was 1.62% (95% CI, 0.85% to 3.10%; I2=95.57%) for studies using self- or parent-reported questionnaires and 0.91% (95% CI, 0.46% to 1.80%; I2=60.98%) for studies utilizing interviews (Supplementary Table 11).

6. Prevalence of FAP-NOS and its sub-analyses

The overall estimated prevalence of AM diagnosed by Rome III and IV criteria is 1.91% (95% CI, 1.53% to 2.37%; I2=95.03%). Specifically, the estimated prevalence of FAP-NOS was 2.30% (95% CI, 1.78% to 2.96%; I2=96.45%) based on Rome III criteria and 0.87% (95% CI, 0.57% to 1.31%; I2=84.28%) based on Rome IV criteria. The estimated prevalence among males was 3.57% (95% CI, 2.70% to 4.72%; I2=83.07%), while females had an estimated prevalence of 4.49% (95% CI, 3.31% to 6.08%; I2=90.49%) across both Rome III and IV criteria (Table 1). The overall prevalence at the country and regional levels according to Rome III and Rome IV criteria is presented in Fig. 5 and Supplementary Tables 13 and 14.

Fig. 5.

Fig. 5

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Global prevalence of FAPD-NOS, 2006 to 2024. Pooled estimates, % for prevalence. This world map was generated using the R software (Version 4.3.3). FAPD-NOS, functional abdominal pain disorder not otherwise specified; NA, not available.

In sub-analyses, the estimated prevalence of FAP-NOS was 3.94% (95% CI, 2.35% to 6.60%; I2=97.52%) based on strict Rome III criteria and 1.95% (95% CI, 1.55% to 2.46%; I2=92.86%) based on approximated Rome III criteria. When stratified by methods of questionnaire administration, the prevalence was 2.17% (95% CI, 1.69% to 2.79%; I2=95.71%) for studies using self- or parent-reported questionnaires and 4.47% (95% CI, 1.45% to 13.73%; I2=98.26%) for studies utilizing interviews (Supplementary Table 13). Additionally, in further sub-analyses, the estimated prevalence was 0.81% (95% CI, 0.44% to 1.49%; I2=85.13%) based on strict Rome IV criteria and 0.85% (95% CI, 0.37% to 1.97%; I2=85.68%) based on approximated Rome IV criteria. When stratified by methods of questionnaire administration, the prevalence was 0.79% (95% CI, 0.49% to 1.28%; I2=80.30%) for studies using self- or parent-reported questionnaires and 1.14% (95% CI, 0.16% to 8.38%; I2=93.84%) for studies utilizing interviews (Supplementary Table 13).

Funnel plot asymmetry was evaluated to assess the risk of publication bias, which was found to be high for the global prevalence of IBS (p<0.001), FD (p<0.001), AM (p<0.001), and FAPD-NOS (p<0.001) based on Egger’s test. Additionally, asymmetry in some subgroup analyses of prevalence studies suggested potential publication bias.

DISCUSSION

This systematic review and meta-analysis included 67 studies encompassing 82 distinct populations of children and adolescents, totaling 1,712,737 individuals from 34 countries, to estimate the prevalence of FAPD and its subtypes based on Rome III and IV criteria. The overall estimated prevalence of FAPD was 10.89% (95% CI, 9.51% to 12.48%; I2=95.90%), with pooled prevalence rates of 11.84% (95% CI, 10.29% to 13.61%; I2=95.66%) under Rome III criteria and 8.42% (95% CI, 6.10% to 11.62%; I2=95.92%) under Rome IV criteria. However, prevalence rates varied widely across countries, ranging from 0.93% (95% CI, 0.06% to 13.15%) in Indonesia to 22.94% (95% CI, 17.83% to 28.98%) in Jordan, underscoring the heterogeneous nature of FAPD epidemiology globally. Among the FAPD subtypes, IBS had the highest prevalence and FD the lowest under Rome III criteria. However, under Rome IV, the prevalence of IBS, AM, and FAP-NOS decreased, whereas FD increased, resulting in approximately one in 23 individuals having FD, one in 51 having IBS, one in 68 having AM, and one in 115 having FAP-NOS. These prevalence estimates also varied significantly across countries and regions. Finally, females exhibited higher prevalence rates of FAPD and all its subtypes compared to males.

The overall prevalence of FAPD was lower under the Rome IV criteria, likely owing to a more restrictive diagnostic framework. The transition from Rome III to Rome IV introduced several modifications that may have influenced prevalence estimates. Among the four subtypes, only FD showed an increase in prevalence under Rome IV, possibly due to the removal of the requirement that pain must be present for diagnosis, allowing FD to be diagnosed based solely on at least one bothersome symptom, such as postprandial fullness or early satiation. Additionally, the required symptom frequency changed from at least once per week to at least four days per month, which collectively contributed to the overall increase in the prevalence of FD.12,14 For IBS, the elimination of the term “discomfort” in Rome IV led to a more stringent diagnostic definition. Additionally, the Rome committee recommends that patients with both constipation and abdominal pain be treated for constipation first. If the pain resolves with constipation treatment alone, the diagnosis is revised to functional constipation rather than IBS, which may further explain the decrease in IBS prevalence.12,14 Moreover, although the subtypes of IBS were not officially defined under the Rome III criteria for pediatric populations, the observed differences in the prevalence of IBS subtypes between Rome III and Rome IV may be attributable to the adoption of the Bristol Stool Form Scale in Rome IV, which enabled a more standardized and objective classification of stool patterns. The introduction of the criterion requiring a “stereotypical pattern and symptoms in the individual patient” in Rome IV, along with the increase in required symptom frequency from twice per 12 months (Rome III) to twice per 6 months (Rome IV), may have contributed to the observed decline in AM prevalence.12,14 The additional requirement that symptoms “do not occur solely during physiological events” may also have influenced the lower prevalence of FAP-NOS observed in Rome IV.12,14 While other epidemiological factors may contribute to these variations, the study by Strisciuglio et al.61 found an increase in FD prevalence and a decrease in the other three subtypes when applying Rome IV instead of Rome III within the same cohort. This pattern aligns with the pooled estimates observed in the present study, suggesting that modifications in diagnostic criteria likely played a significant role in shaping prevalence estimates. The substantial variation in FAPD prevalence across countries may be explained by differences in globally varying risk factors.62 These include psychological distress (such as depression and anxiety), acute infectious gastroenteritis, genetic predisposition, exposure to stressful life events (e.g., trauma and abuse), and obesity.62,63 Females consistently exhibited higher prevalence rates of FAPD and its subtypes than males under both Rome III and Rome IV criteria. This difference may be influenced by sex hormones, as testosterone is known to have a stronger anti-nociceptive effect,64 with genetic variations in the endogenous opioid system also contributing to differences in pain perception.65 Additionally, compared to males, females are more susceptible to poorer sleep quality, greater psychological distress, and higher exposure to childhood abuse, all of which may contribute to their higher prevalence rates.66-68

Recent studies across 33 countries have primarily examined FGID prevalence in adults,69 highlighting the limited focus on pediatric populations. Moreover, despite the substantial burden of FGID, research funding remains insufficient compared to other gastrointestinal diseases.70 Additionally, more restrictive diagnostic criteria of Rome IV compared to Rome III may further reduce recognition and support for pediatric patients. Currently, no approved drugs or therapies exist for FAPD, and its etiology remains under investigation.71 Even with the several effective interventions, including dietary and nutritional support,72 probiotics,73 psychological therapies (e.g., cognitive behavioral therapy and hypnotherapy),74 and pharmacological treatments such as neuromodulators,75 FAPD requires greater attention in both clinical practice and research to adequately address children and adolescents with FAPD. Although Rome IV revisions were made based on clinical rationale,12 they have led to disparities in prevalence estimates due to more stringent diagnostic criteria, potentially leaving patients who previously met Rome III criteria without adequate recognition.61 According to Strisciuglio et al.,61 the use of Rome IV criteria in the same cohort resulted in a decrease in overall FAPD diagnoses, with significant reductions in IBS and AM and a marked increase in FD. These changes suggest that the revised criteria may lead to underdiagnosis or overdiagnosis of specific FAPD subtypes. While the stricter diagnostic criteria may be beneficial for research standardization, clinical care must continue to support these patients.69 Clinicians and researchers should avoid overemphasizing prevalence shifts under Rome IV, as FAPD remains a significant burden for both patients and healthcare systems.76,77

This study has several limitations that should be considered when interpreting the findings. First, there is an uneven distribution of data on FAPD prevalence globally. Studies from Africa and the Middle East are limited, which may affect the generalizability of the results in these regions. To address this, estimates were pooled at both country and regional levels to provide a more comprehensive overview. Second, substantial heterogeneity was observed among the included studies, which may be attributed not only to differences in diagnostic criteria and data collection methods, but also to other unmeasured epidemiological factors that vary across regions and populations. Third, the number of studies reporting prevalence based on Rome IV criteria remains relatively low compared to those using Rome III, potentially limiting the robustness of prevalence estimates under the updated criteria. To mitigate the effects of heterogeneity and variations in diagnostic criteria, sub-analyses were carried out by distinguishing studies that strictly adhered to Rome definitions from those that approximated them. Additionally, studies were categorized based on how questionnaires were administered to assess potential methodological differences. This approach aimed to enhance the accuracy of the pooled estimates while acknowledging the inherent variability in study methodologies. Fourth, the lack of age-specific prevalence estimates limits the ability to fully characterize the epidemiology of FAPD across different pediatric age groups. Fifth, not all studies reported prevalence by sex or FAPD subtype, requiring caution in interpretation, as missing data may introduce bias in sex-stratified or subtype-specific prevalence estimates. Despite these limitations, this study employed a rigorous methodological approach to identify relevant studies reporting FAPD prevalence strictly based on Rome III and IV criteria.12,14 By extracting data exclusively from the general population, it provides a comprehensive representation of FAPD epidemiology. This study also addressed the inherent overlap among FAPD subtypes, where a single patient may meet criteria for multiple subtypes.78 Simply summing the prevalence of individual subtypes risks will likely overestimate the overall FAPD prevalence due to this overlap.79 To ensure accuracy, this analysis was based on studies that directly reported overall FAPD prevalence rather than aggregating subtype-specific rates. Furthermore, by stratifying prevalence estimates based on strict versus approximated diagnostic criteria and methods of questionnaire administration,7 this study enhances the precision and reliability of its findings.

In conclusion, this systematic review and meta-analysis provide valuable insights into the prevalence estimates of FAPD and its subtypes based on Rome III and IV criteria, further stratified by geographic, demographic, and diagnostic factors. The more restrictive diagnostic framework of Rome IV compared to Rome III has likely influenced the estimated prevalence rates of FAPD and its subtypes. However, further research is needed, particularly in regions with limited data, such as Africa and the Middle East, to improve the understanding of FAPD epidemiology.

ACKNOWLEDGEMENTS

This research was supported by grants from the National Research Foundation of Korea (NRF) funded by the Korea government (MSIT; RS–2023–00248157) and the MSIT (Ministry of Science and ICT), Korea, under the ITRC (Information Technology Research Center) support program (IITP-2024-RS-2024-00438239) supervised by the IITP (Institute for Information & Communications Technology Planning & Evaluation). The funders had no role in study design, data collection, data analysis, data interpretation, or writing of the report.

This systematic review article does not require Institutional Review Board approval. Our systematic review and meta-analysis protocol was registered with PROSPERO (Registration No. CRD420251004116).

SUPPLEMENTARY MATERIALS

Supplementary materials can be accessed at https://doi.org/10.5009/gnl250225.

gnl-20-3-427-supple.pdf (585.5KB, pdf)

Footnotes

CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

AUTHOR CONTRIBUTIONS

Study concept and design: Y.D.J., S.K., J.W.H., D.K.Y. Data acquisition, analysis, or interpretation: Y.D.J., S.K., J.W.H., D.K.Y. Drafting of the manuscript: Y.D.J., S.K., J.W.H., D.K.Y. Critical revision of the manuscript for important intellectual content: all authors. Statistical analysis: Y.D.J., S.K., J.W.H., D.K.Y. Study supervision: J.W.H., D.K.Y. Approval of final manuscript: all authors.

DATA AVAILABILITY STATEMENT

All data generated or analyzed during this study are included in this published article and its supplementary materials.

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