Evaluating the role of the Bristol stool chart in diagnosing functional constipation in pediatric populations

doi:10.5409/wjcp.v15.i2.118424

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Jun 9, 2026 (publication date) through May 16, 2026

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World Journal of Clinical Pediatrics

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2219-2808

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

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Copyright: ©Author(s) 2026. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution-NonCommercial (CC BY-NC 4.0) license. No commercial re-use. See permissions. Published by Baishideng Publishing Group Inc.

World J Clin Pediatr. Jun 9, 2026; 15(2): 118424
Published online Jun 9, 2026. doi: 10.5409/wjcp.v15.i2.118424

Evaluating the role of the Bristol stool chart in diagnosing functional constipation in pediatric populations

Kriangsak Ounboontham, Thitima Ngoenmak

Kriangsak Ounboontham, Thitima Ngoenmak, Department of Pediatrics, Faculty of Medicine, Naresuan University, Mueang 65000, Phitsanulok, Thailand

Co-first authors: Kriangsak Ounboontham and Thitima Ngoenmak.

Author contributions: Ounboontham K and Ngoenmak T contributed to conceptualization, study design, material preparation, data acquisition, and analysis; Ngoenmak T contributed to drafting and revising the manuscript and approved the submission of the final version; and all authors have read and approved the final version of the manuscript.

AI contribution statement: ChatGPT, Grammarly, and QuillBot were used at an early stage solely to assist with grammar checking and language refinement in certain parts of the manuscript. No AI tools were used for data analysis, study design, or interpretation of the results. All statistical analyses were performed in consultation with a statistics unit, and calculations were conducted using STATA software. No images in the manuscript were generated by AI.

Supported by the Faculty of Medicine, Naresuan University, No. MD 69E006.

Institutional review board statement: The study was reviewed and approved by the Ethics Committee of Naresuan University, Institutional Review Board (Approval No. P3-0034/2568).

Informed consent statement: All study participants, or their legal guardians, provided written consent before study enrollment.

Conflict-of-interest statement: All authors declare that they have no conflict of interest to disclose.

STROBE statement: The authors have read the STROBE Statement-checklist of items-and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.

Data sharing statement: Data set available from the corresponding author at thitiman@nu.ac.th. Participants gave informed consent for data sharing.

Corresponding author: Thitima Ngoenmak, MD, Associate Professor, Department of Pediatrics, Faculty of Medicine, Naresuan University, 99 Moo 9 Tha-pho subdistrict, Mueang 65000, Phitsanulok, Thailand. thitiman@nu.ac.th

Received: January 6, 2026
Revised: February 9, 2026
Accepted: March 16, 2026
Published online: June 9, 2026
Processing time: 128 Days and 1.3 Hours

Abstract

BACKGROUND

Functional constipation (FC) is a common condition among children worldwide. Although the Rome IV criteria are diagnostic standard, evaluating infants and toddlers can be challenging. The Bristol stool chart (BSC) is a simple tool for describing stool consistency, but its diagnostic accuracy in young children is uncertain.

AIM

To compare the diagnostic performance of the BSC and Rome IV criteria in children under four years.

METHODS

A prospective cross-sectional study was conducted from June 2025 to October 2025 among children aged 6 months to 4 years attending well-child visits at the Hospital. Parents completed validated Thai versions of the Rome IV questionnaire and the BSC. FC was diagnosed using the Rome IV criteria. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the BSC were calculated.

RESULTS

Among 275 children enrolled, 43 (15.6%) met the Rome IV criteria for FC. The FC group had a significantly higher mean age than the non-FC group (30.1 ± 11.9 months vs 21.2 ± 12.2 months, P < 0.001). A family history of constipation was associated with increased FC prevalence (P = 0.017). On the BSC, stool types 1-2 indicated constipation. Compared with the Rome IV criteria, the BSC demonstrated sensitivity of 48.8%, specificity of 98.3%, PPV of 84.0%, and NPV of 91.2%.

CONCLUSION

The BSC shows high specificity but low sensitivity in young children; stool types 1-2 support FC and are best used to confirm diagnosis alongside the Rome IV criteria.

Keywords: Children; Functional constipation; Bristol stool chart; Pediatric; Prevalence

Core Tip: Stool assessment tools are essential for evaluating pediatric constipation. The Bristol stool chart (BSC) is widely used but has limitations when applied to young children. BSC use should be integrated with clinical judgment and other diagnostic criteria, such as the Rome IV criteria. The BSC exhibits the highest accuracy when classifying stools at the extremes. BSC types 1-2 may serve as supportive indicators for confirming functional constipation.