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Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN

Tabbers, M.M.; DiLorenzo, C.; Berger, M.Y.; Faure, C.; Langendam, M.W.; Nurko, S.; Staiano, A.; Vandenplas, Y.; Benninga, M.A.

Journal of Pediatric Gastroenterology & Nutrition:
doi: 10.1097/MPG.0000000000000266
Guidelines | Society Papers | Consensus Statements

Background: Constipation is a pediatric problem commonly encountered by many health care workers in primary, secondary, and tertiary care. To assist medical care providers in the evaluation and management of children with functional constipation, the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition were charged with the task of developing a uniform document of evidence-based guidelines.

Methods: Nine clinical questions addressing diagnostic, therapeutic, and prognostic topics were formulated. A systematic literature search was performed from inception to October 2011 using Embase, MEDLINE, the Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Clinical Trials, and PsychInfo databases. The approach of the Grading of Recommendations Assessment, Development and Evaluation was applied to evaluate outcomes. For therapeutic questions, quality of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation system. Grading the quality of evidence for the other questions was performed according to the classification system of the Oxford Centre for Evidence-Based Medicine. During 3 consensus meetings, all recommendations were discussed and finalized. The group members voted on each recommendation, using the nominal voting technique. Expert opinion was used where no randomized controlled trials were available to support the recommendation.

Results: This evidence-based guideline provides recommendations for the evaluation and treatment of children with functional constipation to standardize and improve their quality of care. In addition, 2 algorithms were developed, one for the infants <6 months of age and the other for older infants and children.

Conclusions: This document is intended to be used in daily practice and as a basis for further clinical research. Large well-designed clinical trials are necessary with regard to diagnostic evaluation and treatment.

Author Information

Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands.

Address correspondence and reprint requests to Merit M. Tabbers, MD, PhD, Emma Children's Hospital/Academic Medical Centre, H7-250, PO Box 22700, 1100 DD Amsterdam, The Netherlands (e-mail:

Received 23 November, 2013

Accepted 25 November, 2013

Drs Tabbers and DiLorenzo contributed equally to the article.

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Guideline development was financially supported by NASPGHAN and ESPGHAN. No other support was received from industry.

C.D.L. is a consultant for Janssen, Sucampo, AstraZeneca, and Ironwood. C.F. is a consultant for Sucampo. S.N. is a consultant for Janssen and Sucampo. A.S. is a consultant for Valeas and DMG Italy. Y.V. is a consultant for Biocodex and United Pharmaceuticals. M.B. is a consultant for Shire and Sucampo. The other authors report no conflicts of interest.

© 2014 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,