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Clinical Practice Guideline

Evaluation and Treatment of Constipation in Children: Summary of Updated Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition

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Journal of Pediatric Gastroenterology and Nutrition: September 2006 - Volume 43 - Issue 3 - p 405-407
doi: 10.1097/01.mpg.0000232574.41149.0a
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Constipation, defined as a delay or difficulty in defecation present for 2 or more weeks, is a common pediatric problem. The stooling pattern of children is a concern of many families, and any deviation from what is thought to be normal may cause families to seek medical advice. To assist primary care pediatricians, family practitioners, nurse practitioners, physician assistants, pediatric gastroenterologists and pediatric surgeons in the management of children with constipation, the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) Constipation Guideline Committee published a medical position paper in 1999 based on a literature search completed in November 1998 (1). To evaluate the potential impact of new information published since then, the committee performed a systematic and comprehensive review of the medical literature and critically reviewed the new evidence.


Literature searches, using the key word "constipation," limited to the English language, and "all child" (which includes children and adolescents 0-18 years of age) were performed in PubMed on May 5, 2003, August 8, 2003, and August 9, 2004. The Database of Abstracts of Reviews of Effects and Cochrane Database of Systematic Reviews were also searched using the key word "constipation." In the most recent search, 90 total articles were identified by this process; 27 applied to children who did not have an underlying chronic condition. The authors identified an additional 8 articles during the subsequent discussions. The quality of evidence was categorized according to Fisher and Eckhard (2). The articles were reviewed in detail and discussed by the Constipation Guideline Committee until consensus was achieved on whether the original recommendations should be modified based on the new evidence.



There are conflicting reports about the role of intake of dietary fiber, with evidence that constipated children have a lower, equivalent or higher intake of dietary fiber (3-6). Administration of glucomannan (7) in addition to laxatives may be beneficial in the treatment of constipation. Until additional studies demonstrate the efficacy of treatment with fiber, the current findings are too weak to support a definitive recommendation for fiber supplementation in the treatment of constipation.

Polyethylene Glycol (PEG) 3350

Eleven studies (8-18) were published on the use of PEG 3350 for children with constipation. One study (8), a prospective, double-blind, parallel, randomized study of 4 doses of PEG 3350 (0.25, 0.5, 1 and 1.5 g/kg/d) given for 3 days in children who had constipation for more than 3 months and evidence of fecal impaction, assessed the effectiveness of PEG 3350 as an agent for disimpaction. This study showed that PEG 3350 is effective for the treatment of childhood fecal impaction at a dose of 1 to 1.5 g/kg/d. The other studies focused on maintenance treatment for constipation and suggest that PEG is safe, effective and well accepted. There is no study suggesting that PEG 3350 is superior to other cheaper or more traditional agents. One retrospective study (18) found that administration of a maintenance dose of 0.78 g/kg/d of PEG 3350 to infants younger than 18 months for an average duration of 6 months was not associated with any significant side effect.

Polyethylene glycol 3350 is efficacious for disimpaction in children. When daily medication is necessary in the treatment of constipation, PEG 3350 appears to be superior to other osmotic agents in palatability and acceptance by children. Preliminary clinical data in 12 infants suggest that administration of PEG 3350 to infants is effective with no adverse effects noted. Further safety studies need to be done before widespread use can be recommended in infants.


For most children with constipation, the benefits of cisapride do not outweigh the risks (19-22). The committee does not recommend its use.


Since 1997, 6 publications (23-28) on biofeedback, including 1 review in the Cochrane Database of Systematic Reviews (24), failed to show long-term efficacy for biofeedback. In 1 study (23), 49 children, with mean age of 8 years, with chronic idiopathic constipation, were randomized to receive biofeedback or conventional therapy. During a short observation time (3 months), the children in the biofeedback group improved more than the children in the conventional therapy group. The committee reaffirmed its original recommendation that biofeedback therapy can be an effective short-term treatment of intractable constipation in a small subgroup of patients.

Cow's Milk

Four (29-32) studies were published on the relationship between cow's milk and constipation. Two of the studies (29,30) showed that a subgroup of constipated children improved on a diet without cow's milk and relapsed when challenged with cow's milk. Another study (31) suggested that constipation may be a delayed clinical reaction to cow's milk in children intolerant to cow's milk. The most recent study found that constipation and anal fissures were more likely to occur in infants and toddlers consuming a larger amount of cow's milk. The children who had improvement of constipation on a diet without cow's milk were more likely to have a personal or family history of atopy, and many of the patients had anal fissures and perianal erythema. Children with constipation and anal fissures had more cutaneous and respiratory symptoms. The children enrolled in these studies were mostly patients referred to pediatric gastroenterology clinics, and how generalizable these findings are to primary care physicians or other pediatric gastroenterology clinics is uncertain. In children unresponsive to conventional medical and behavioral management, consideration may be given to a time-limited trial of cow's milk-free diet.


Based on this review the recommendations of the original NASPGHAN guideline on constipation were reaffirmed, with several being modified according to the new evidence. The complete updated guideline is available in its entirety.1

NASPGHAN Constipation

Guideline Committee

  • Susan S. Baker, MD
  • Buffalo, NY
  • Gregory S. Liptak, MD
  • Syracuse, NY
  • Richard B. Colletti, MD
  • Burlington, VT
  • Joseph M. Croffie, MD
  • Indianapolis, IN
  • Carlo Di Lorenzo, MD
  • Columbus, OH
  • Walton Ector, MD
  • Charleston, SC
  • Samuel Nurko, MD
  • Boston, MA.


1. Baker SS, Liptak GS, Colletti RB, et al. Constipation in infants and children: evaluation and treatment. J Pediatr Gastroenterol Nutr 1999;29:612-26.
2. Fisher M, Eckhard C, eds. Guide to Clinical Preventive Services: An Assessment of the Effectiveness of 169 Interventions. Report of the US Preventive Services Task Force. Baltimore: Williams and Wilkins, 1989:387-8.
3. Roma E, Adamidis D, Nikolara R, et al. Diet and chronic constipation in children: the role of fiber. J Pediatr Gastroenterol Nutr 1999;28:169-74.
4. Moaris MB, Vitolo MR, Aguirre ANC, et al. Measurement of low dietary fiber intake as a risk factor for chronic constipation in children. J Pediatr Gastroenterol Nutr 1999;29:132-5.
5. Guimaraes EV, Goulart EMA, Penna FJ. Dietary fiber intake, stool frequency and colonic transit time in chronic functional constipation in children. Braz J Med Biol Res 2001;34:1147-53.
6. Speridiao PGL, Tahan S, Fagundes-Neto U, et al. Dietary fiber, energy intake and nutritional status during the treatment of children with chronic constipation. Braz J Med Biol Res 2003;36:753-9.
7. Loening-Baucke V, Miele E, Staiano A. Fiber (glucomannan) is beneficial in the treatment of childhood constipation. Pediatrics 2004;113:e259-64.
8. Youssef NN, Peters JM, Henderson W, et al. Dose response of PEG 3350 for the treatment of childhood fecal impaction. J Pediatr 2002;141:410-4.
9. Ferguson A, Culbert P, Gillett H, et al. New polyethylene glycol electrolyte solution for the treatment of constipation and faecal impaction. Ital J Gastroenterol Hepatol 1999;31:S249-52.
10. Staiano A. Use of polyethylene glycol solution in functional and organic constipation in children. Ital J Gastroenterol Hepatol 1999;31:S260-3.
11. Loening-Baucke V. Polyethylene glycol without electrolytes for children with constipation and encopresis. J Pediatr Gastroenterol Nutr 2002;34:372-7.
12. Pashankar DS, Bishop WP. Efficacy and optimal dose of daily polyethylene glycol 3350 for treatment of constipation and encopresis in children. J Pediatr 2001;139:428-32.
13. Gremse DA, Hixon J, Crutchfield A. Comparison of polyethylene glycol 3350 and lactulose for treatment of chronic constipation in children. Clin Pediatr 2002;41:225-9.
14. Pashankar DS, Loening-Baucke V, Bishop WP. Safety of polyethylene glycol 3350 for the treatment of chronic constipation in children. Arch Pediatr Adolesc Med 2003;57:661-4.
15. Bell EA, Wall GC. Pediatric constipation therapy using guidelines and polyethylene glycol 3350. Ann Pharmacother 2004;38:686-93.
16. Erickson BA, Austin JC, Cooper CS, et al. Polyethylene glycol 3350 for constipation in children with dysfunctional elimination. J Urol 2003;170:1518-20.
17. Pashankar DS, Bishop WP, Loening-Baucke V. Long-term efficacy of polyethylene glycol 3350 for the treatment of chronic constipation in children with and without encopresis. Clin Pediatr 2003;42:815-9.
18. Michail S, Gendy E, Preud'Homme D, et al. Polyethylene glycol for constipation in children younger than eighteen months old. J Pediatr Gastroenterol Nutr 2004;39:197-9.
19. Nurko S, Garcia-Aranda JA, Woron LB, et al. Cisapride for the treatment of constipation in children: a double-blind study. J Pediatr 2000;136:35-40.
20. Halabi IM. Cisapride in management of chronic pediatric constipation. J Pediatr Gastroenterol Nutr 1999;28:199-202.
21. Doig Miller V. Use of cisapride in treatment of constipation in children. J Pediatr Gastroenterol Nutr 1997;25:199-203.
22. Staiano A, Andreotti MR, Greco L, et al. Long term follow up of children with chronic idiopathic constipation. Dig Dis Sci 1994;39:561-4.
23. Sunic-Omejc M, Mihanovic M, Bilic A, et al. Efficiency of biofeedback therapy for chronic constipation in children. Coll Antropol 2002;26:93-101.
24. Brazzelli M, Griffiths P. Behavioural and cognitive interventions with or without other treatments for defaecation disorders in children. Cochrane Database Syst Rev 2006;4:CD002240.
25. Coulter ID, Favreau JT, Hardy ML, et al. Biofeed-back interventions for gastrointestinal conditions: a systematic review. Altern Ther Health Med 2002;8:76-83.
26. McGrath ML, Mellon MW, Murphy L. Empirically supported treatments in pediatric psychology: constipation and encopresis. J Pediatr Psychol 2000;25:225-54.
27. Ferrara A, DeJesus S, Gallagher JT, et al. Time-related decay of the benefits of biofeedback therapy. Tech Coloproctol 2001;5:131-5.
28. van der Plas RN, Benninga MA, Taminiau JA, et al. Treatment of defaecation problems in children: the role of education, demystification and toilet training. Eur J Pediatr 1997;156:689-92.
29. Silva D, Soraia T, Dirceu S, et al. Cow's milk protein intolerance and chronic constipation in children. Pediatr Allergy Immunol 2001;12:339-42.
30. Iacono G, Cavataio F, Moltalto G, et al. Intolerance of cow's milk and chronic constipation in children. N Engl J Med 1998;339:1100-4.
31. Carroccio A, Montalt G, Custro N, et al. Evidence of very delayed clinical reactions to cow's milk in cow's milk-intolerant patients. Allergy 2000;55:574-9.
32. Andiran F, Dayi S, Mete E. Cows milk consumption in constipation and anal fissure in infants and young children. J Paediatr Child Health 2003;39:329-331.


© 2006 Lippincott Williams & Wilkins, Inc.