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Functional constipation — Clinical Guidelines

Overview

Functional constipation is a prevalent condition in both pediatric and adult populations, characterized by difficult or infrequent passage of stool without an identifiable organic cause, significantly impacting quality of life and necessitating standardized management approaches 1 4.

Diagnosis

Key Diagnostic Criteria: Absence of red flags on history and examination 6.

Recommended Tests:

- Anorectal manometry is commonly used, especially in intractable cases 3. - Colonic transit studies may be considered, particularly before surgical interventions 3. - Rome IV criteria should guide diagnosis 2 7.

Management

First-Line Treatments:

- Non-pharmacological: Increased fluid intake, dietary fiber, behavioral interventions 8. - Pharmacological: Osmotic laxatives (polyethylene glycol for >1 year old, lactulose/lactitol for <1 year old) 6.

Adjunctive Treatments:

- Stimulant laxatives may be used in specific cases 6. - Pelvic floor physical therapy for refractory cases 2. - High-dose polyethylene glycol for fecal disimpaction 4.

Special Populations

Pediatrics:

- Early diagnosis and appropriate treatment are crucial 5. - Use of polyethylene glycol for disimpaction and osmotic laxatives for maintenance therapy 6.

Adults:

- Anorectal function testing can triage care effectively in refractory cases 2.

Key Recommendations

Diagnose functional constipation only in the absence of red flags (Evidence: Strong 6).

Initiate treatment with non-pharmacological interventions such as increased fluid intake, dietary fiber, and behavioral modifications (Evidence: Moderate 8).

Use osmotic laxatives like polyethylene glycol for maintenance therapy in children >1 year old and lactulose/lactitol for those <1 year old (Evidence: Moderate 6).

Consider anorectal function testing in adults with refractory functional constipation to guide further management (Evidence: Moderate 2).

Disimpact patients with fecal impaction using high-dose polyethylene glycol (Evidence: Moderate 4).

Refer to pediatric gastroenterology specialists for intractable cases or when specific diagnostic tests are needed (Evidence: Expert opinion 3).

References

1 Gordon M, de Geus A, Banasiuk M, Benninga MA, Borrelli O, Boruta M et al.. ESPGHAN and NASPGHAN 2024 protocol for paediatric functional constipation treatment guidelines (standard operating procedure). BMJ paediatrics open 2025. link 2 Shah ED, Ahuja NK, Brenner DM, Chan WW, Curley MA, Nee J et al.. Optimizing the Management Algorithm for Adults With Functional Constipation Failing a Fiber/Laxative Trial in General Gastroenterology: Cost-Effectiveness and Cost-Minimization Analysis. The American journal of gastroenterology 2024. link 3 van der Zande JMJ, Koppen IJN, Yacob D, Sanchez RE, Puri NB, Vaz K et al.. Current practice in the care of children with functional constipation: What is the hold up?. Journal of pediatric gastroenterology and nutrition 2024. link 4 Osatakul S, Benninga MA, Thapar N, Treepongkaruna S, Puetpaiboon A. The magnitude and management of functional constipation at pediatric gastroenterology clinics: A survey study of various countries. Journal of gastroenterology and hepatology 2022. link 5 Casias A, Newton L. Functional Constipation: A Case Report. Journal of pediatric health care : official publication of National Association of Pediatric Nurse Associates & Practitioners 2021. link 6 Yachha SK, Srivastava A, Mohan N, Bharadia L, Sarma MS. Management of Childhood Functional Constipation: Consensus Practice Guidelines of Indian Society of Pediatric Gastroenterology, Hepatology and Nutrition and Pediatric Gastroenterology Chapter of Indian Academy of Pediatrics. Indian pediatrics 2018. link 7 Barnes J, Coleman B, Hwang S, Stolic A, Bousvaros A, Nurko S et al.. Educational needs in the diagnosis and management of pediatric functional constipation: a US survey of specialist and primary care clinicians. Postgraduate medicine 2018. link 8 Yang CH, Punati J. Practice patterns of pediatricians and trainees for the management of functional constipation compared with 2006 NASPGHAN guidelines. Journal of pediatric gastroenterology and nutrition 2015. link

Functional constipation