Review
Copyright ©The Author(s) 2023.
World J Gastroenterol. Feb 28, 2023; 29(8): 1261-1288
Published online Feb 28, 2023. doi: 10.3748/wjg.v29.i8.1261
Table 1 Prevalence of functional constipation in children according to Rome IV and factors associated with functional constipation
Ref.
Country
Population
Sample size
Age
Method of data collection
Prevalence of FC, n
Factors associated with FC
Huang et al[139], 2021China4 community hospitals in Jinhua and Shanghai26040-4 yrGuardian interview92 (3.5%)Vaginal delivery (OR = 0.01, 95%CI: 0.00-0.17), forceps delivery (OR: > 999, 95%CI: 154 to > 999)
Chew et al[140], 2021MalaysiaA well child clinic, University Malaya medical center5341-12 moGuardian interview6 (1.1%)NA
Ibrahim et al[141], 2020EgyptRandomly schools in Cairo 10824-18 yrNA91 (8.4%)NA
Khayat et al[142], 2021Saudi ArabiaPublic survey (random) from Western3173-18 yrQuestionnaire by Google form/links share on social apps15 (4.7%)Guardian characteristics, family income, gender, age, development, previous covid ìnfection (P > 0.05)
Benzamin et al[29], 2022BangladeshSchools of Dhaka division7075-16 yrChild interview and examination (face to face)134 (19%)Female (P = 0.003), age (P = 0.001), history of FC in siblings/parents (P = 0.001), fibers intake (P = 0.002), fluid intake (P = 0.001), electronic screen time (P = 0.001)
Siajunboriboon et al[143], 2022Thailand2 high schools170014-18 yrChild interview138 (8.1%)Guardian characteristics, BMI, history of allergic diseases (P > 0.05)
Chia et al[144], 2022VietnamA government hospital and a government kindergarten15110-48 moGuardian interview and examination (face to face)46 (3%)Male (OR = 3.6, 95%CI: 1.5-8.5), bottle feeding (OR = 18.5, 95%CI: 1.5-219.4), low income (OR = 5.8, 95%CI: 1.7-19.3)
Asia8455522 (6.2%)
Zwiener et al[145], 2017United StatesOnline survey10754-18 yrGuardian interview144 (13.4%)NA
Saps et al[146], 2018Colombia12 schools in 6 cities35678-18 yrChild interview382 (10.7%)NA
Robin et al[147], 2018United StatesOnline survey panels by CINT, United States12550-18 yrGuardian interview186 (14.8%)NA
Játiva-Mariño E et al[148], 2019Ecuador1 public and 1 private school9518-15 yrChild interview137 (14.4%)NA
Saps et al[149], 2020Colombia6 outpatient clinics13341-48 moGuardian interview (face to face)281 (15.1%)NA
Velasco-Benitez et al[150], 2020Colombia4 public schools149710-18 yrGuardians interview194 (13%)NA
Baaleman et al[151], 2021ColombiaA public school11811-18 yrChild interview16 (13.6%)NA
Velasco-Benítez et al[152], 2021Colombia5 to 8 grade students in Cali46510-18 yrChildren interview52 (28.7%)NA
Dos Santos et al[27], 2021BrazilPublic parks and school areas7995-14 yrGuardian interview163 (20.4%)Sex, type of school (P > 0.05)
de Morais et al[153], 2022BrazilPediatric private clinics in 5 regions45600-12 moGuardian interview341 (7.6%)Age 162-248 d (OR = 1.41, 95%CI: 1.01-1.95), prematurity (OR = 1.44, 95%CI: 1.02-2.02)
America156211896 (12.1%)
Russo et al[21], 2019ItalyGeneral clinics2141 mo-17 yrGuardian/child interview(face to face)39 (18.2%)NA
Vladimir et al[154], 2019RussiaUniversity clinic3000-48 moGuardian interview45 (15%)NA
Steutel et al[155], 2020Belgium, Italy, NetherlandGeneral pediatrics hospital (Belgium, Italy) and well-baby clinic (the Netherlands)27510-48 moGuardian interview and examination (face to face)151 (5.4%)NA
Campeotto et al[156], 2020FrancePrivate out-patient pediatricians and general practitioner15700-12 moGuardian interview and examination (face to face)141 (9%)NA
Alonso-Bermejo et al[157], 2022SpainA pediatric gastroenterology clinic5740-16 yrGuardian/child interview and examination (face to face)41 (7.1%)NA
Beser et al[158], 2021Turkey9 tertiary Hospital23831-12 moChild interview and examination (face to face)112 (4.7%)NA
Strisciuglio et al[159], 20226 Mediterranean countries1Nursery schools, primary schools and secondary schools, randomly43534-18 yrGuardian interview475 (10.9%)NA
Europe121451004 (8.3%)
Bellaiche et al[160], 202010 countries in Africa2Children with gastrointestinal symptoms104580-12 moGuardians interview and examination (face to face)3283 (31.4%)NA
Africa104583283 (31.4%)
All over the world466796704 (14.4%)
Table 2 Rome IV criteria for pediatric functional constipation[6,7,9]
Child’s age
Diagnostic criteria
< 4 years oldTwo or more criteria for at least 1 mo1: (1) Two or fewer defecations per week; (2) History of excessive stool retention; (3) History of painful or hard bowel movements; (4) History of large diameter stools; (5) Presence of a large fecal mass in the rectum; (6) At least one episode of fecal incontinence per week after the acquisition of toileting skills; and (7) History of large-diameter stools that may obstruct the toilet in toilet trained children
≥ 4 years oldTwo or more symptoms for at least 1 mo in children at least 4 yr2: (1) Two or fewer defecations per week; (2) At least one episode of fecal incontinence per week; (3) History of retentive posturing or excessive stool retention; (4) History of painful or hard bowel movements; (5) Presence of a large fecal mass in the rectum; (6) History of large-diameter stool that may obstruct the toilet; and (7) Additional criteria: Without fulfilling irritable bowel syndrome criteria
Table 3 Alarm signs and symptoms of constipation[37]
Alarm signs
Symptoms of constipation
HistoryConstipation starting in neonatal period, delay pass meconium (> 48 h of life), family history of Hirschsprung’s disease
Stool characteristicsRibbon stools, blood in the stools in the absence of anal fissures
Gastrointestinal featuresBilious vomiting, severe abdominal distension
BackSacral dimple, tuft of hair on spine, gluteal cleft deviation
AnusPerianal fistula, abnormal position of anus, anal scar, absent anal/cremasteric reflex
Neurological featuresDecreased lower extremity strength/tone/reflex
OthersAbnormal thyroid gland, fever, faltering of growth
Table 4 Organic causes of constipation[1]
Organic causes

Abnormalities of colon and rectumAnal or colonic stenosis. Imperforate anus. Anteriorly displaced or ectopic anus. Cloacal malformations. Chronic intestinal pseudo-obstruction
Systemic disordersHypothyroidism. Hypercalcemia. Hypocalcemia. Diabetes mellitus. Panhypopituitarism. Cerebral palsy. Myotonia congenita. Scleroderma. Amyloidosis. Mixed connective tissue disease. Myotonic dystrophy. Progressive systemic sclerosis
OthersCystic fibrosis. Celiac disease. Heavy metal ingestion (lead, mercury)
Spinal cord abnormalitiesMeningomyelocele. Spinal cord tumor. Sacral agenesis. Tethered cord
Neuropathic intestinal disordersHirschsprung’s disease. Intestinal neuronal dysplasia. Chagas disease. Abnormal muscle of abdomen. Prune belly syndrome. Gastroschisis
DrugsOpiates. Anticholinergics. Antacids. Antihypertensives. Antimotility agents. Cholestyramine. Psychotropics. Diuretics
Table 5 Laxatives used for functional constipation in children[1,6,37,58]
Agent
Child’s age
Dosage
Side effects
Osmotic laxatives
PEG Any age0.4-0.8g/kg per day for maintenance; 1-1.5g/kg per day for fecal disimpactionDiarrhea, bloating, flatulence, nausea, vomiting, abdominal cramps
Lactulose (70% solution)Any age1 mL/kg once or twice daily (max 120 mL per day)Bloating, flatulence, abdominal cramps, fecal, incontinence
Sorbitol (70% solution)1-11 yr1 mL/kg once or twice daily (max 30 mL per day)Bloating, abdominal cramps
> 12 yr15-30 mL once or twice daily
Milk of magnesium> 2 yr1-3 mL/kg per day once or twice dailyAbdominal pain, fecal incontinence, hypermagnesaemia, hypocalcaemia, hypophosphataemia (with excess use in children with renal disease)
Stimulant laxatives
Senna (antraquinone)> 2 yr7.5-15 mg/kg per day once dailyAbdominal cramps, idiosyncratic hepatitis, melanosis coli in prolong used, nephropathy, neuropathy, hypertrophic osteoarthropathy
Bisacodyl> 2 yr5-10 mg per day once dailyDiarrhoea, abdominal cramps
Sodium picosulphate4-5 yr3 mg per dayNausea, vomiting, bloating, abdominal cramps, diarrhea, headache, taste impairment
> 6 yr4-6 mg per day
Glycerine suppository< 1 yrHalf for pediatric suppository once dailyRectal irritation, bloating, abdominal cramps, diarrhea
Rectal laxatives/enemas
Sodium phosphate> 1 yr2.5 mg/kgRectal discomfort, diarrhea, abdominal cramps, electrolyte imbalance
Bisacodyl2-12 yr5 mg/dose once dailyRectal discomfort, diarrhea, abdominal cramps, hypokalemia
> 12 yr5-10 mg/dose once daily
Saline enemaNeonate< 1 kg: 5 mL, > 1 kg: 10 mLRectal discomfort, bloating
> 1 yr6 mL/kg once or twice daily
Lubricant
Mineral oil> 1 yr1-2 mL/kg daily (max 90 mL per day)Rectal discomfort, lipoid pneumonitis
Table 6 Characteristics of randomized controlled trials assessing the effects of herbal medications in children with constipation
Ref.
Country
Age (yr)
Study design
No. case (intervention/ control)
Intervention protocol
Probably pharmacological effect of herbal medicine
Duration of treatment/follow-up/end point and outcome measurement
Treatment effect
Esmaeilidooki et al[99], 2016Iran2-15Open label, RCT, single center109 (52/57)CFE 1 mL/kg per day in three-divided doses (equivalent to 0.1 g of dried pulp of fruits of Cassia fistula). PEG 0.7-0.8g/kg per dayPhenolic antioxidants such as flavonoids, flavan-3-ol derivatives and anthraquinones: Stimulant laxativeTreatment for 4 wk. Primary outcome: Frequencies of defecation, severity of pain, consistency of stool, fecal incontinence and retentive posturing. Secondary: The safety and compliance of therapyAfter 4 wk: 86.5% of children in CFE group and 77.1% in PEG group exited from the criteria of FC (RR = 1.121, CI95%: 0.939-1.338). Frequency of defecation that in CFE group (10.96 ± 5.7 stools per week) was significantly more than PEG group (6.9 ± 3.5 stools per week) (P < 0.001). No serious adverse effects in both groups (25% diarrhea and 3.8% abdominal pain)
Cai et al[161], 2018China1-14Double-bline RCT, multicenter480 (120/360)XEBT: (1) 1-3 years old: 2.5 g, 3 times a day; (2) 4-6 years old: 5 g, 2 times a day; and (3) > 7 years old: 5 g, 3 times a day. PlaceboSeven herbs (Houpo contains magnolol, JueMingZi contain anthraquinones, LuHui contains reactive Aloe-emodin, BaiZhu contains Atractylodes japonica, LaiFuZi, XingRen, ZhiQiao): Promote small bowel peristalsis and work against atropine-induced small intestine suppression in miceTreatment for 14 daysPrimary outcome: Frequency of SBM for 14 d. Secondary outcomes: Effectual time of defecation, mean symptom scores, disappearance rate of symptoms, recurrence rate and safety outcomesThe mean value of SBM for 14 d were 8.89 and 5.63 in the XEBT and placebo group (P < 0.05). The median effectual time of defecation, main symptom score and disappearance rate of symptoms were significant improved in XEBT group without the significant minor adverse effects between groups
Dehghani et al[101], 2019Iran4-12Double-blind RCT, single center92 (45/47)BSM (sugarcane extract) 1 mL/kg per day. PEG 1 g/kg per dayThe BSM naturally contained polyphenols (960 μg/mL), potassium (12430 μg/mL), iron (10 μg/mL), calcium (3320 μg/mL), zinc (22 μg/mL), sucrose (296000 μg/mL), triterpenoids (11230 μg/mL), phytosterols (7 μg/mL), flavonoids (2 μg/mL and polysaccharides (1250 μg/mL): Polysaccharide act as bulk forming agent, flavonoids/phytosterols and polyphenolic compounds act as natural antioxidants and anti-inflammatory agentsTreatment for 4 wk: Primary outcome: Response rate improvement in frequency of defecations per week, absence of lumpy or hard stools, abdominal pain and retention, soiling and blood-stained stool, sensation of anorectal obstruction/blockage. Secondary outcome: Patients’ body weigh was measured in every visit and serological parameters (count blood cells, BUN, creatinine, calcium, phosphorus, sodium and potassium)Defecation per week was significantly improved in both groups. Symptoms including volitional stool retention, large diameter stool, painful or hard stool and large fecal mass in the rectum decreased significantly two and four weeks after intervention (P < 0.05). No significant difference between the groups. No adverse effects were observed
Qiao et al[102], 2021China4-14Double-blind RCT, multicenter study200 (100/100)Mixture of 12 herbs1 (XiaojiDaozhi Decoction) and placebo (5% drug ingredients and 95% dextrin). All received fiber 20 g per day and toilet training)12.5% Raphanus sativus L. (facilitating intestinal motility), 8.33% Areca catechu L. (stimulating gastrointestinal cholinergic receptor), 6.67% Fructus aurantll immaturus (stimulate gastrointestinal smooth muscle), Citrus aurantium L. (stimulate gastrointestinal smooth muscle), 6.67% Crataegus pinnatifida (stimulate gastrointestinal smooth muscle), Magnolia officinalis Rehd (stimulate gastrointestinal smooth muscle), Cannabis sativa L. (moistening the bowel and purging the stools), Atractylodesmacrocephala Koidz. (stimulate gastrointestinal smooth muscle), Semen armeniacae amarum (purgative effect), Paeonia lactiflora Pall, Radix et rhizoma rhei, (purgative stool)0 and honey (moistening the bowel and purgative effect)Treatment for 8 wk and follow-up for 12 wk. Primary outcome: Complete SBM (≥ 3 per week) and satisfaction with bowel function. Secondary outcome: Safety and adverse effect (blood measurement of liver and kidney function and lead level)After 8 wk: 56% of CHM group and 25% of placebo satified with bowel movement (P < 0.05). 40% of CHM group and 19% of placebo had complete spontaneous bowel movement (P < 0.05). No serious adverse effects in both groups
Tavassoli et al[162], 2021Iran4-10Open label RCT, single center133 (66/67)Viola flower syrups 5 mL, 3 times a day. PEG 4000 1 g/kg per dayViola flower contains crude methanolic extract, butanolic and aqueous extracts the stimulate gastrointestinal motilityTreatment 4 wk. Primary outcome: Response off treatment (ROME III criteria). Secondary outcome: Stool consistency, defecation frequency, hard stools, painful defecation, fecal retention, and fecal soilingBoth groups demonstrated significant improvement in stool consistency, number off defecation, hard stool, painful defecation, fecal retention and fecal soiling at the end of the study compared to baseline (P < 0.001). No significant difference was observed between the two groups at baseline or at the end of the study (P > 0.05)
Nasri et al[163], 2021Iran2-15Open-lable RCT120 (60/60)LaxaPlus Barij Syrup 1 mL/kg divided into 3 doses. PEG 0.7 g/kgNATreatment and follow-up 8 wk. Primary outcome: Stool consistency, number of defecations, intensity of pain, fecal incontinence. Secondary outcome: Satisfaction rateAfter 8 wk follow-up: Bowel movements in the intervention group was significantly higher than in the control group (P < 0.05). Pain intensity, and abdominal pain in the group LaxaPlus Barij® decreased significant than control group. No different about satisfaction rate between 2 group
Saneian et al[103], 2021Iran2-15Double-blind RCT60 (30/30)Goleghand (including honey and Rosa damascene) 0.5 g/kg in three divided dose. PEG: 0.7 g/kgNATreatment and follow-up 8 wk. Primary outcome: The number and consistency of stools per day, painful defecation, abdominal pain, and fecal incontinence. Secondary outcome: Adverse effects and parental satisfactionAfter 8 wk: The number of fecal defecations in Goleghand group was higher than PEG (P < 0.05). The decrease of defecations after following was more significant in the PEG group than in the Goleghand® group (P = 0.001). Parental satisfaction scores did not change in either group (P > 0.05)
Imanieh et al[104], 2022Iran1-18Double-blind RCT100 (50/50)Rosa damascena + brown sugar 1-2 mL/kg (1 mL composed of 0.1 g damask rose and 0.85 g brown sugar). PEG 1-2 mL/kg. All received high fiber diet and hydrationDamask rose: Osmotic laxatives and prokinetic effect. Brown sugar: Osmotic laxatives effect. Possible active ingredients might be phenolic compounds and aqueous fraction (terpenes, glucosides, flavonoids, anthocyanins, kaempferol and quercetin)Treatment and follow-up 4 wk. Primary outcome: the effective of herbs with PEG. Secondary outcome: Adverse effectsAfter 4 wk: The cure rate was 100% in the R. damascena group and 91.7% in the control group. Adverse effect of intervention group was the taste which was too sweet
Table 7 Recommend water intake per day[164]

Total water intake per day, including water contained in food (mL)
Infants 0-6 mo700 (water is assumed to be from breast) milk
7-12 mo800 (milk and complementary foods and beverages)
1-3 yr1300
4-8 yr1700
Boys 9-13 yr2400
Girls 9-13 yr2100
Boys 14-18 yr3300
Girls 14-18 yr2300