In 2014, the European and North American Societies for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN and NASPGHAN) issued guidelines on the management of paediatric constipation using1:

  • Lifestyle modifications (diet, fluid, exercise);
  • Oral and/or rectal laxatives;
  • Behavioural therapy;
  • Transabdominal electrical stimulation or sacral nerve stimulation;
  • Surgical management: colectomy or stoma, including anterograde irrigation

However, new and emerging developments are occurring within each management option.

Recent developments in the management of constipation

Lifestyle modifications

Available evidence suggests that a dietary fibre intake of 2 g per 1000 kJ (239 kcal) is considered adequate for normal laxation in children aged >1 year.2 Accordingly, the ESPGHAN and NASPGHAN guidelines recommend that children with constipation have a normal fibre and fluid intake (0.7–1.8 L/day, depending on age)3, with daily physical activities remaining unchanged (ie, up to 180 minutes of physical activity daily, depending on a child’s age),1,4,5 because, while extra / supplemental fibre can increase defecation rates in children, it is no more effective than a placebo.3


Chronic constipation can be managed using oral laxatives, such as milk of magnesia (magnesium hydroxide) or polyethylene glycol (PEG), to increase water content in the stool,1 with PEG providing slightly better outcomes for stool frequency, form of stool, abdominal pain and the need for additional medication.6

While enemas are not very popular, they are a useful treatment for improving bowel function in constipated patients. Discomfort, pain, embarrassment and expense mean that these procedures are generally avoided in children with constipation.

Novel pharmacological agents

Pharmacological agents, such as prucalopride, lubiprostone and linaclotide, have demonstrated efficacy in the management of constipation in adult patients through numerous mechanisms, including triggering the peristaltic reflex, increasing gut motility and increasing smooth muscle contraction.7-15 However, further data is awaited before they are granted marketing approval for paediatric patients.

Behavioural therapy

In children who have not responded to oral or rectal laxatives, a range of new treatment strategies may be applied, such as transabdominal electrical stimulation (TES) or sacral nerve stimulation. There is currently moderate support for the effectiveness of TES in the treatment of slow-transit constipation with improvements seen in defecation frequency, abdominal pain and laxative use.16-18 However, studies encompassing larger and more diverse patient populations who have been followed for longer periods of time are necessary to reliably determine the efficacy of TES in the treatment of constipation in children.

Sacral nerve stimulation is also a promising new treatment for constipation,19-22 but this treatment is very expensive and as a result is generally considered to be a last resort. Biofeedback therapy is another alternate therapy for constipation where the governing principle is that any behaviour, when reinforced repeatedly, can be learned and perfected. For example, visual or verbal feedback is given to encourage a child’s awareness of the urge to defecate, and to relax their external anal sphincter in response.23 However, there is currently no evidence to support the use of biofeedback therapy for the treatment of childhood constipation.23

Surgical management

The majority of studies exploring surgical management options for childhood constipation are case series discussing a limited number of patients.24 Furthermore, research has been hampered by an absence of a clear definition of constipation, failure to ascertain the patients’ duration of symptoms, a wide range of definitions of success and a lack of assessment of patient or carer satisfaction or quality of life.24 Therefore, there is limited data on the use of surgery to manage constipation in children, and it continues to be limited to very specific cases with a clear indication.

Traditional Asian medicines in the management of constipation

Traditional herbal medicines tend to play a greater role in Asia than Europe, although studies report that, overall, one in three people with constipation may use herbal therapies, often in combination with conventional therapies.25 Investigations of a variety of Japanese and Chinese herbal medicines have reported conflicting results.26-31

Acupuncture, another traditional Chinese medicine may also have efficacy in patients with constipation, improving physical symptoms, such as spontaneous defecation times, abdominal pain and evacuation difficulty, as well as sensory symptoms, such as endless sensation of defecation and obstruction sense of anus.32 This can reduce laxative prescription dependence and improve patient quality of life, but data supporting the use of acupuncture in children with constipation is lacking.32


Children with constipation should have a normal fibre and fluid intake, and engage in daily physical activity.1 If an additional intervention is required, PEG is the first choice as a maintenance treatment because evidence does not support the use of any non-pharmacological treatment in childhood constipation, and while novel pharmacological therapies have demonstrated efficacy in adult populations, further studies in children are required before these can be made available.1 Likewise, while there is some evidence to support the use of traditional Asian medicines, such as herbal remedies or acupuncture, to manage constipation, there is little data to support their use in children.25-32



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