Addressing functional constipation in children: A call for comprehensive and collaborative management

Abstract

Functional constipation (FC) is the most common gastrointestinal disorder in children, with a global prevalence of 14.4% based on Rome IV criteria. This editorial explores the multifactorial pathogenesis and diagnostic complexity of FC, emphasizing the importance of early and accurate diagnosis. Effective management of FC hinges on child-oriented toilet training and the use of osmotic laxatives, particularly polyethylene glycol. Emerging therapies, including probiotics, serotonin 5-HT4 receptor agonists, chloride channel activators, and herbal remedies, offer promising options but require further research. Lifestyle modifications, such as adequate fiber and fluid intake and physiotherapy, are crucial in supporting pharmacological treatments. For intractable cases, a multidisciplinary approach involving pediatric specialists, nutritionists, physiotherapists, and psychologists is essential. This comprehensive strategy aims to improve the quality of life for children with FC and their families through continuous research, education, and collaborative care.

Key Words: Functional constipation; Gastrointestinal disorder; Children; Management

Core Tip: Functional constipation is the most common gastrointestinal disorder in children, affecting 14.4% globally. Effective management requires a multifaceted approach involving child-oriented toilet training and the use of osmotic laxatives, particularly polyethylene glycol. Emerging therapies such as probiotics and serotonin 5-HT4 receptor agonists show promise but need further research. Lifestyle modifications, including adequate fiber and fluid intake and physiotherapy, support treatment. For intractable cases, a multidisciplinary approach involving pediatric specialists, nutritionists, physiotherapists, and psychologists is essential to address both physical and psychological aspects, thereby improving the quality of life for affected children and their families.

TO THE EDITOR

Functional constipation (FC) stands as the most prevalent gastrointestinal disorder among children, with a global prevalence of 14.4% based on the Rome IV criteria[1]. This condition poses significant challenges not only due to its multifaceted pathophysiology but also because of the psychological and social ramifications it has on affected children and their families (Figure 1). The impact of FC extends beyond physical discomfort, affecting children's quality of life, academic performance, and social interactions. Moreover, diagnosing and treating FC remains complex due to symptom overlap with other disorders, limited diagnostic tools, and the multifactorial nature of the condition.

Figure 1 Article content introduction.

Multifactorial pathogenesis and diagnostic complexity

FC arises from a combination of stool withholding behavior, anorectal dysfunctions, dietary factors, physical activity levels, genetic predispositions, and psychological issues[2]. Each of these factors contributes to the complexity of the condition, making it challenging to manage effectively. Early and accurate diagnosis is paramount, yet it remains challenging due to the overlap of symptoms with other gastrointestinal disorders. The Rome IV criteria offer a structured approach for diagnosis, emphasizing the importance of detailed medical history and physical examination. However, cases with persistent or severe symptoms often necessitate further investigations to rule out organic causes. These investigations might include imaging studies, laboratory tests, and in some instances, specialized procedures like colonic manometry or rectal biopsies. Understanding the multifactorial nature of FC helps in tailoring individualized treatment plans that address not just the physical symptoms but also the underlying behavioral and psychological factors[3].

The role of toilet training and osmotic laxatives

The cornerstone of FC management lies in effective toilet training and the use of osmotic laxatives. Toilet training should be child-oriented, starting ideally between 18 and 24 months, and reinforced with positive parental support. This method involves gradually helping the child develop regular toilet habits without any pressure or negative reinforcement[4]. The use of polyethylene glycol (PEG) as the first-line laxative has shown considerable efficacy in increasing bowel movement frequency and improving stool consistency. PEG works by retaining water in the stool, making it softer and easier to pass. However, concerns about long-term laxative use necessitate continuous monitoring and reassurance for parents. PEG, a widely used and trusted treatment, has proven efficacy in managing FC with a relatively low side effect profile. Therefore, a direct comparison between emerging treatments and PEG—addressing factors like long-term effectiveness, potential adverse effects, ease of use, and patient adherence—could provide clinicians with a clearer understanding of the advantages and limitations of newer options. This would help ensure that emerging therapies are not only evaluated for their innovation but also for their clinical practicality in the context of everyday treatment settings. It is important for healthcare providers to educate families on the safety and effectiveness of PEG, while also discussing potential side effects and ensuring that the treatment plan is adhered to over the long term[5]. Regular follow-ups are essential to monitor progress and make necessary adjustments to the treatment regimen.

Emerging therapies and lifestyle modifications

Recent advances have introduced promising therapeutic options, including probiotics, serotonin 5-HT4 receptor agonists, chloride channel activators, and herbal remedies. Probiotics, for instance, are believed to restore the balance of gut microbiota, potentially improving bowel habits. Serotonin 5-HT4 receptor agonists and chloride channel activators help enhance intestinal motility, offering new hope for patients who do not respond to conventional treatments. Despite their potential, these treatments require more rigorous research to establish their safety and efficacy. Concurrently, lifestyle modifications such as adequate fiber and fluid intake, and physiotherapy play crucial roles in supporting pharmacological treatments. A diet rich in fiber helps to increase stool bulk and promote regular bowel movements, while sufficient fluid intake ensures proper hydration and facilitates bowel function. Physiotherapy, particularly pelvic floor exercises, can also be beneficial in improving bowel habits and reducing symptoms of constipation. Integrating these lifestyle changes into the daily routine of children with FC can significantly enhance treatment outcomes and improve their overall quality of life[6].

Multidisciplinary approach for intractable cases

For children with intractable constipation, a multidisciplinary approach is essential. Pediatric specialists, nutritionists, physiotherapists, and psychologists must collaborate to develop individualized treatment plans. This team-based approach ensures comprehensive care that addresses both the physical and psychological aspects of FC. Pediatric specialists can provide medical management and monitor progress, while nutritionists can offer dietary guidance to ensure adequate fiber and fluid intake. Physiotherapists can help with exercises to improve bowel function, and psychologists can address any underlying behavioral or emotional issues that may contribute to the condition. In some cases, other specialists such as gastroenterologists or surgeons may be involved to manage more severe or refractory cases. This collaborative approach not only improves the chances of successful treatment but also provides families with the support they need to manage the condition effectively.

An in-depth discussion on the diagnostic challenges and criteria for FC in children is crucial for early identification and effective management. Diagnosing FC is complex because it relies heavily on clinical assessment, as there are no definitive tests or biomarkers. Symptoms like abdominal pain, infrequent stools, and straining overlap with both functional and organic constipation, making differentiation difficult. While common constipation may result from lifestyle factors, FC often involves more complex issues such as delayed bowel motility, pelvic floor dysfunction, or psychosocial factors. Therefore, a comprehensive approach, including a detailed history and collaboration among healthcare professionals, is essential to accurately distinguish FC from other forms of constipation and provide tailored treatment.

CONCLUSION

FC in children is a complex disorder that requires a multifaceted approach for effective management. For example, distinguishing between FC and organic causes of constipation can be particularly challenging due to symptom overlap and the lack of specific markers. A deeper exploration of the diagnostic difficulties, including the role of clinical history, physical examination, and the use of emerging diagnostic tools or biomarkers, would add value. Highlighting the potential of novel approaches, such as non-invasive biomarkers or advanced imaging techniques, could further enhance the accuracy of differentiation and guide clinical decision-making. A clear, structured follow-up plan is essential for ensuring that treatment efficacy is regularly assessed. For example, follow-up visits should be scheduled at specific intervals, such as every 3 months during the maintenance phase, to monitor the child’s progress and make necessary adjustments. In addition, criteria for adjusting treatment plans based on patient response should be outlined, such as increasing the dose of osmotic laxatives or adding new therapies when symptoms persist. It is also crucial to provide clear indicators for when to refer to specialists, such as persistent symptoms despite appropriate treatment or the presence of complicating factors like psychosocial issues or underlying medical conditions. These comprehensive management strategies will ensure that children receive tailored, ongoing care, improving their quality of life and reducing the burden on families. Patient and family education is essential in managing FC in children. Educating families about the causes of FC, the importance of treatment adherence, and lifestyle modifications, such as dietary changes and toilet training, can significantly improve outcomes. Clear communication about the safety and effectiveness of treatments like PEG helps build trust and ensures better adherence. Providing families with practical knowledge and support empowers them to play an active role in the child’s care, enhancing the overall management of FC. While toilet training and osmotic laxatives remain the mainstay of treatment, emerging therapies and lifestyle modifications offer additional support. A multidisciplinary approach is crucial for managing intractable cases, ensuring that all aspects of the child's health are addressed. Continuous research and education are imperative to improve outcomes and provide evidence-based care for children with FC. Emerging diagnostic tools, such as gut motility imaging and non-invasive biomarker analysis, hold potential for earlier and more accurate diagnosis. Additionally, advancements in digital health technologies, like mobile apps for symptom tracking and adherence monitoring, could enhance patient management. By fostering a collaborative and comprehensive management strategy, we can significantly improve the quality of life for children suffering from FC and their families. Ensuring that healthcare providers are well-informed about the latest advancements in FC management and maintaining open communication with families are key steps in achieving better health outcomes for these children.