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    Functional constipation: A guideline review

    Recommendations on how to diagnose and treat this common malady keep evolving. One expert reviews the latest guidelines supported by the most up-to-date evidence.

    Functional constipation in children is a common problem. Prevalence rates worldwide range between 0.7% and 30%, with a higher prevalence found in younger children (aged 2 to 6 years) compared with older children, and often in children during times of change. Children aged 5 to 6 years have the highest reported prevalence (35.4%).1 The burden of this condition on children, families, and society is highlighted by data showing that children with constipation use more health services than those without constipation, and incur an estimated additional cost of 3.9 billion per year.2 This childhood health problem is no news to pediatricians. It is estimated that 3% of all visits to general pediatricians are for functional constipation, and the problem accounts for up to 25% of visits to pediatric gastroenterologists.1

    What may be news is that recommendations on how to diagnose and treat this common malady keep evolving as more evidence becomes available. To keep up with this evolution, the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) developed a joint guideline that presents the most up-to-date evidence.3 Published in 2014, the guideline updates an earlier 2006 guideline by the NASPGHAN.4

    In 2015, a study that looked at how pediatricians apply the updated 2014 guidelines found that about 84% of those surveyed reported no or only slight familiarity with the updated guidelines.5 The study highlighted the need for more education on functional constipation in children, with a particular emphasis on updating pediatricians via the new guideline on the proper use of medications to reduce time to remission, among other issues.

    To help broaden the reach of the guidelines so that pediatricians are up-to-date on the latest evidence on the diagnosis and treatment of functional constipation in children, Samuel Nurko, MD, MPH, Center for Motility and Functional Gastrointestinal Disorders, Boston Children’s Hospital, Massachusetts, discussed the key recommendations presented in the guidelines at the 2015 American Academy of Pediatrics (AAP) annual conference.

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    In his presentation “Got Colon Congestion? New Evidence-Based Guidelines for Evaluating and Treating Functional Constipation in Kids,”6 Nurko emphasized 2 take-home messages supported by the latest evidence: 1) X-rays and other tests are not needed to diagnose functional constipation in most children as it is a symptom-based diagnosis, and 2) treatment incudes education and pharmacologic treatment, the latter of which should be administered for at least 2 months and be only gradually discontinued after resolution of constipation symptoms for 1 month.


    The first step to diagnosing functional constipation is knowing what it is. Similar to the criteria used in the 2006 guidelines, the updated 2014 guidelines recommend using the widely accepted Rome III definitions to define functional constipation.3 Since the publication of the 2014 guidelines, updated Rome IV definitions have been published that are similar to Rome III definitions but with 1 change indicating a shorter duration of symptoms needed to define constipation (from 2 months to 1 month).7,8 Tables 1 and 2 list Rome IV definitions for functional constipation in children aged 4 years and younger and children aged 4 years and older, respectively. For children aged younger than 4 years, irritability, decreased appetite, and/or early satiety may accompany the symptoms of constipation. These symptoms may disappear immediately after the child passes a large stool.

    Making the diagnosis is based on history and physical examination, which are done to also rule out other potential underlying conditions such as anatomic malformations, neuroenteric disorders, neuropathic conditions, metabolic endocrine and gastrointestinal disorders, psychologic problems, systemic problems, and drugs.

    NEXT: Recommendations against using imaging

    Mary Beth Nierengarten, MA
    Mary Beth Nierengarten is a freelance medical writer with over 25 years of experience. Her work appears regularly in a number of print ...


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