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©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
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], 2021 | China | 4 community hospitals in Jinhua and Shanghai | 2604 | 0-4 yr | Guardian interview | 92 (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], 2021 | Malaysia | A well child clinic, University Malaya medical center | 534 | 1-12 mo | Guardian interview | 6 (1.1%) | NA |
| Ibrahim et al[141], 2020 | Egypt | Randomly schools in Cairo | 1082 | 4-18 yr | NA | 91 (8.4%) | NA |
| Khayat et al[142], 2021 | Saudi Arabia | Public survey (random) from Western | 317 | 3-18 yr | Questionnaire by Google form/links share on social apps | 15 (4.7%) | Guardian characteristics, family income, gender, age, development, previous covid ìnfection (P > 0.05) |
| Benzamin et al[29], 2022 | Bangladesh | Schools of Dhaka division | 707 | 5-16 yr | Child 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], 2022 | Thailand | 2 high schools | 1700 | 14-18 yr | Child interview | 138 (8.1%) | Guardian characteristics, BMI, history of allergic diseases (P > 0.05) |
| Chia et al[144], 2022 | Vietnam | A government hospital and a government kindergarten | 1511 | 0-48 mo | Guardian 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) |
| Asia | 8455 | 522 (6.2%) | |||||
| Zwiener et al[145], 2017 | United States | Online survey | 1075 | 4-18 yr | Guardian interview | 144 (13.4%) | NA |
| Saps et al[146], 2018 | Colombia | 12 schools in 6 cities | 3567 | 8-18 yr | Child interview | 382 (10.7%) | NA |
| Robin et al[147], 2018 | United States | Online survey panels by CINT, United States | 1255 | 0-18 yr | Guardian interview | 186 (14.8%) | NA |
| Játiva-Mariño E et al[148], 2019 | Ecuador | 1 public and 1 private school | 951 | 8-15 yr | Child interview | 137 (14.4%) | NA |
| Saps et al[149], 2020 | Colombia | 6 outpatient clinics | 1334 | 1-48 mo | Guardian interview (face to face) | 281 (15.1%) | NA |
| Velasco-Benitez et al[150], 2020 | Colombia | 4 public schools | 1497 | 10-18 yr | Guardians interview | 194 (13%) | NA |
| Baaleman et al[151], 2021 | Colombia | A public school | 118 | 11-18 yr | Child interview | 16 (13.6%) | NA |
| Velasco-Benítez et al[152], 2021 | Colombia | 5 to 8 grade students in Cali | 465 | 10-18 yr | Children interview | 52 (28.7%) | NA |
| Dos Santos et al[27], 2021 | Brazil | Public parks and school areas | 799 | 5-14 yr | Guardian interview | 163 (20.4%) | Sex, type of school (P > 0.05) |
| de Morais et al[153], 2022 | Brazil | Pediatric private clinics in 5 regions | 4560 | 0-12 mo | Guardian interview | 341 (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) |
| America | 15621 | 1896 (12.1%) | |||||
| Russo et al[21], 2019 | Italy | General clinics | 214 | 1 mo-17 yr | Guardian/child interview(face to face) | 39 (18.2%) | NA |
| Vladimir et al[154], 2019 | Russia | University clinic | 300 | 0-48 mo | Guardian interview | 45 (15%) | NA |
| Steutel et al[155], 2020 | Belgium, Italy, Netherland | General pediatrics hospital (Belgium, Italy) and well-baby clinic (the Netherlands) | 2751 | 0-48 mo | Guardian interview and examination (face to face) | 151 (5.4%) | NA |
| Campeotto et al[156], 2020 | France | Private out-patient pediatricians and general practitioner | 1570 | 0-12 mo | Guardian interview and examination (face to face) | 141 (9%) | NA |
| Alonso-Bermejo et al[157], 2022 | Spain | A pediatric gastroenterology clinic | 574 | 0-16 yr | Guardian/child interview and examination (face to face) | 41 (7.1%) | NA |
| Beser et al[158], 2021 | Turkey | 9 tertiary Hospital | 2383 | 1-12 mo | Child interview and examination (face to face) | 112 (4.7%) | NA |
| Strisciuglio et al[159], 2022 | 6 Mediterranean countries1 | Nursery schools, primary schools and secondary schools, randomly | 4353 | 4-18 yr | Guardian interview | 475 (10.9%) | NA |
| Europe | 12145 | 1004 (8.3%) | |||||
| Bellaiche et al[160], 2020 | 10 countries in Africa2 | Children with gastrointestinal symptoms | 10458 | 0-12 mo | Guardians interview and examination (face to face) | 3283 (31.4%) | NA |
| Africa | 10458 | 3283 (31.4%) | |||||
| All over the world | 46679 | 6704 (14.4%) |
| Child’s age | Diagnostic criteria |
| < 4 years old | Two 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 old | Two 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 |
| History | Constipation starting in neonatal period, delay pass meconium (> 48 h of life), family history of Hirschsprung’s disease |
| Stool characteristics | Ribbon stools, blood in the stools in the absence of anal fissures |
| Gastrointestinal features | Bilious vomiting, severe abdominal distension |
| Back | Sacral dimple, tuft of hair on spine, gluteal cleft deviation |
| Anus | Perianal fistula, abnormal position of anus, anal scar, absent anal/cremasteric reflex |
| Neurological features | Decreased lower extremity strength/tone/reflex |
| Others | Abnormal thyroid gland, fever, faltering of growth |
Table 4 Organic causes of constipation[1]
| Organic causes | |
| Abnormalities of colon and rectum | Anal or colonic stenosis. Imperforate anus. Anteriorly displaced or ectopic anus. Cloacal malformations. Chronic intestinal pseudo-obstruction |
| Systemic disorders | Hypothyroidism. Hypercalcemia. Hypocalcemia. Diabetes mellitus. Panhypopituitarism. Cerebral palsy. Myotonia congenita. Scleroderma. Amyloidosis. Mixed connective tissue disease. Myotonic dystrophy. Progressive systemic sclerosis |
| Others | Cystic fibrosis. Celiac disease. Heavy metal ingestion (lead, mercury) |
| Spinal cord abnormalities | Meningomyelocele. Spinal cord tumor. Sacral agenesis. Tethered cord |
| Neuropathic intestinal disorders | Hirschsprung’s disease. Intestinal neuronal dysplasia. Chagas disease. Abnormal muscle of abdomen. Prune belly syndrome. Gastroschisis |
| Drugs | Opiates. Anticholinergics. Antacids. Antihypertensives. Antimotility agents. Cholestyramine. Psychotropics. Diuretics |
| Agent | Child’s age | Dosage | Side effects |
| Osmotic laxatives | |||
| PEG | Any age | 0.4-0.8g/kg per day for maintenance; 1-1.5g/kg per day for fecal disimpaction | Diarrhea, bloating, flatulence, nausea, vomiting, abdominal cramps |
| Lactulose (70% solution) | Any age | 1 mL/kg once or twice daily (max 120 mL per day) | Bloating, flatulence, abdominal cramps, fecal, incontinence |
| Sorbitol (70% solution) | 1-11 yr | 1 mL/kg once or twice daily (max 30 mL per day) | Bloating, abdominal cramps |
| > 12 yr | 15-30 mL once or twice daily | ||
| Milk of magnesium | > 2 yr | 1-3 mL/kg per day once or twice daily | Abdominal pain, fecal incontinence, hypermagnesaemia, hypocalcaemia, hypophosphataemia (with excess use in children with renal disease) |
| Stimulant laxatives | |||
| Senna (antraquinone) | > 2 yr | 7.5-15 mg/kg per day once daily | Abdominal cramps, idiosyncratic hepatitis, melanosis coli in prolong used, nephropathy, neuropathy, hypertrophic osteoarthropathy |
| Bisacodyl | > 2 yr | 5-10 mg per day once daily | Diarrhoea, abdominal cramps |
| Sodium picosulphate | 4-5 yr | 3 mg per day | Nausea, vomiting, bloating, abdominal cramps, diarrhea, headache, taste impairment |
| > 6 yr | 4-6 mg per day | ||
| Glycerine suppository | < 1 yr | Half for pediatric suppository once daily | Rectal irritation, bloating, abdominal cramps, diarrhea |
| Rectal laxatives/enemas | |||
| Sodium phosphate | > 1 yr | 2.5 mg/kg | Rectal discomfort, diarrhea, abdominal cramps, electrolyte imbalance |
| Bisacodyl | 2-12 yr | 5 mg/dose once daily | Rectal discomfort, diarrhea, abdominal cramps, hypokalemia |
| > 12 yr | 5-10 mg/dose once daily | ||
| Saline enema | Neonate | < 1 kg: 5 mL, > 1 kg: 10 mL | Rectal discomfort, bloating |
| > 1 yr | 6 mL/kg once or twice daily | ||
| Lubricant | |||
| Mineral oil | > 1 yr | 1-2 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], 2016 | Iran | 2-15 | Open label, RCT, single center | 109 (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 day | Phenolic antioxidants such as flavonoids, flavan-3-ol derivatives and anthraquinones: Stimulant laxative | Treatment 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 therapy | After 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], 2018 | China | 1-14 | Double-bline RCT, multicenter | 480 (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. Placebo | Seven 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 mice | Treatment 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 outcomes | The 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], 2019 | Iran | 4-12 | Double-blind RCT, single center | 92 (45/47) | BSM (sugarcane extract) 1 mL/kg per day. PEG 1 g/kg per day | The 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 agents | Treatment 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], 2021 | China | 4-14 | Double-blind RCT, multicenter study | 200 (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], 2021 | Iran | 4-10 | Open label RCT, single center | 133 (66/67) | Viola flower syrups 5 mL, 3 times a day. PEG 4000 1 g/kg per day | Viola flower contains crude methanolic extract, butanolic and aqueous extracts the stimulate gastrointestinal motility | Treatment 4 wk. Primary outcome: Response off treatment (ROME III criteria). Secondary outcome: Stool consistency, defecation frequency, hard stools, painful defecation, fecal retention, and fecal soiling | Both 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], 2021 | Iran | 2-15 | Open-lable RCT | 120 (60/60) | LaxaPlus Barij Syrup 1 mL/kg divided into 3 doses. PEG 0.7 g/kg | NA | Treatment and follow-up 8 wk. Primary outcome: Stool consistency, number of defecations, intensity of pain, fecal incontinence. Secondary outcome: Satisfaction rate | After 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], 2021 | Iran | 2-15 | Double-blind RCT | 60 (30/30) | Goleghand (including honey and Rosa damascene) 0.5 g/kg in three divided dose. PEG: 0.7 g/kg | NA | Treatment 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 satisfaction | After 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], 2022 | Iran | 1-18 | Double-blind RCT | 100 (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 hydration | Damask 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 effects | After 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 mo | 700 (water is assumed to be from breast) milk |
| 7-12 mo | 800 (milk and complementary foods and beverages) |
| 1-3 yr | 1300 |
| 4-8 yr | 1700 |
| Boys 9-13 yr | 2400 |
| Girls 9-13 yr | 2100 |
| Boys 14-18 yr | 3300 |
| Girls 14-18 yr | 2300 |
- Citation: Tran DL, Sintusek P. Functional constipation in children: What physicians should know. World J Gastroenterol 2023; 29(8): 1261-1288
- URL: https://www.wjgnet.com/1007-9327/full/v29/i8/1261.htm
- DOI: https://dx.doi.org/10.3748/wjg.v29.i8.1261