Paediatrics: how to manage functional constipation

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Background: Despite being a common problem in childhood, functional constipation is often difficult to manage. This article provides a narrative updated review on the evaluation, diagnosis and management of childhood functional constipation.

Methods: A PubMed search was performed with Clinical Queries using the key term ‘functional constipation’. The search strategy included clinical trials, meta-analyses, randomized controlled trials, observational studies and reviews. The search was restricted to the English literature and to the paediatric population. The information retrieved from the above search was used in the compilation of the present article.

Results: A detailed history and thorough physical examination are important in the evaluation of a child with constipation to establish the diagnosis of functional constipation as per the Rome IV criteria and to catch ‘red flags’ suggestive of organic causes of constipation. These ‘red flags’ include delayed passage of meconium, ribbon stool, rectal bleeding/blood in the stool unless attributable to an anal fissure, failure to thrive, severe abdominal distension, absent anal wink/cremasteric reflex, tight and empty rectum on digital examination and explosive expulsion of liquid stool and gas on withdrawal of the finger, hair tuft/dimple/lipoma/haemangioma in the lumbosacral area, and an anteriorly displaced anus. For functional constipation, pharmacological therapy consists of faecal disimpaction and maintenance therapy. This can be effectively accomplished with oral medications, rectal medications or a combination of both. The most commonly used and most effective laxative is polyethylene glycol. Non-pharmacological management consists of education, behavioural modification and dietary interventions. The combination of pharmacological therapy and nonpharmacological management increases the chance of success.

Conclusion: Polyethylene glycol is the medication of first choice for both disimpaction and maintenance therapy. If polyethylene glycol is not available or is poorly tolerated, lactulose is the preferred alternative. Other laxatives may be considered as second-line therapy if treatment with osmotic laxatives fails or is insufficient. Maintenance treatment should be continued for at least 2 months. Early treatment will result in a faster and shorter treatment course.

Keywords: bulky stools, hard stools, infrequent defecation, laxatives, painful defecation, polyethylene glycol.

Citation: Leung AKC, Hon KL. Paediatrics: how to manage functional constipation. Drugs in Context 2021; 10: 2020-11-2. DOI: 10.7573/dic.2020-11-2

Contributions: Professor Alexander KC Leung is the principal author. Professor Kam Lun Hon is a co-author who contributed and helped with the drafting of this manuscript. All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this article, take responsibility for the integrity of the work as a whole, and have given their approval for this version to be published.

Disclosure and potential conflicts of interest: Professor Alexander KC Leung and Professor Kam Lun Hon are associate editors of Drugs in Context and confirm that this article has no other conflicts of interest otherwise. The International Committee of Medical Journal Editors (ICMJE) Potential Conflicts of Interests form for the authors is available for download at:

Acknowledgements: None.

Funding declaration: There was no funding associated with the preparation of this article.

Copyright: Copyright © 2021 Leung AKC, Hon KL. Published by Drugs in Context under Creative Commons License Deed CC BY NC ND 4.0 which allows anyone to copy, distribute, and transmit the article provided it is properly attributed in the manner specified below. No commercial use without permission.

Correct attribution: Copyright © 2021 Leung AKC, Hon KL. Published by Drugs in Context under Creative Commons License Deed CC BY NC ND 4.0.

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Correspondence: Alexander KC Leung, University of Calgary, Alberta Children’s Hospital, #200, 233 – 16th Avenue NW, Calgary, Alberta, Canada T2M 0H5. Email:

Provenance: Invited; externally peer reviewed.

Submitted: 9 November 2020; Accepted: 6 January 2021; Publication date: 26 March 2021.

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