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European Society for Paediatric Gastroenterology, Hepatology and Nutrition/North American Society for Pediatric Gastroenterology, Hepatology and Nutrition guidelines for treatment of functional constipation in children aged 0–18 years

ESPGHAN/NASPGHAN · 2026 · Europe

Source and licence

Authors
Morris Gordon, Anna de Geus, Mary Boruta et al.
Title
European Society for Paediatric Gastroenterology, Hepatology and Nutrition/North American Society for Pediatric Gastroenterology, Hepatology and Nutrition guidelines for treatment of functional constipation in children aged 0–18 years
Journal
Journal of Pediatric Gastroenterology and Nutrition, 2026
DOI
10.1002/jpn3.70447
Licence
CC BY 4.0
Changes
Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC13446596

Licence statement of the original publication

This is an open access article under the terms of the http://creativecommons.org/licenses/by/4.0/ License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.

Open the original publication →Full text on Europe PMC

Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

Good practice statements

  • The Guideline Development Group (GDG) suggests that consideration and management of fecal impaction is vital to ensure long‐term therapeutic success with any maintenance therapy. The GDG acknowledges that the lack of a clear definition for fecal impaction influences assessment in practice and is a barrier to achieving successful disimpaction.
  • The GDG suggests that high‐dose polyethylene glycol or enemas can be used as treatment options for fecal impaction.
  • The GDG also recognizes other treatments that have utility in disimpaction and may be used under locally agreed standardized protocols.

GRADE recommendations

  • Polyethylene glycol with or without electrolytes is recommended as a treatment option for functional constipation (FC) in childrenstrong recommendation, overall moderate certainty evidence, effect size moderate
  • Magnesium (hydr)oxide is suggested as a treatment option for FC in childrenconditional recommendation, overall low certainty evidence, effect size small
  • Prucalopride is not suggested as a treatment option for FC in childrenconditional recommendation, overall moderate certainty evidence, no effect
  • Linaclotide is suggested as a treatment option for FC in childrenconditional recommendation, overall moderate certainty evidence, effect size small
  • Enemas are not suggested as routine add on to maintenance laxative treatment for FC in children (conditional recommendation, overall low certainty evidence, no effect) (please also see the GPS)

Good practice statements

  • The GDG suggests that lactulose has a therapeutic role for FC in children.
  • The GDG suggests that bisacodyl has a therapeutic role for FC in children.
  • The GDG suggests that senna has a therapeutic role for FC in children.
  • The GDG suggests that sodium picosulfate has a therapeutic role for FC in children.
  • The GDG suggests that liquid paraffin has a therapeutic role for FC in children. However, routine use is not recommended due to the potential significant side effects.
  • The GDG does not suggest the use of lubiprostone as a treatment for FC in children.
  • The GDG does not suggest the use of domperidone as a treatment for FC in children.
  • General statement regarding rectal therapies: The GDG acknowledges the potential psychosocial impact of all per rectum therapies. The decision to consider such therapies should be shared with children and their families, taking key factors into account.
  • The GDG suggests enemas have a maintenance therapeutic role for FC in select children.
  • The GDG suggests rectal suppositories have a therapeutic role for FC in select cases, either as an adjunct or as an alternative when other therapies are not effective or appropriate.
  • The GDG suggests transanal irrigation has a therapeutic role for FC in select cases (where other therapies are not effective or appropriate) and under specialized expert care.
  • The GDG suggests botulinum toxin A injections have a therapeutic role for FC in select cases (refractory to conventional treatments) under specialized expert care.

GRADE recommendations

  • A specific probiotic mixture (containing: Lactobacillus acidophilus, Bifidobacterium longum, and Streptococcus thermophilus) is suggested as a treatment option for FC in childrenconditional recommendation, overall low certainty evidence, effect size small
  • A specific synbiotic preparation (multi‐strain probiotics and prebiotics*) is suggested as a treatment option for FC in childrenconditional recommendation, overall low certainty evidence, effect size large
  • Cow's milk‐free diet trial for 2–4 weeks is suggested as an adjunct treatment option for FC in children not responding to conventional therapy alone and when cow's milk allergy is suspectedconditional recommendation, overall low certainty evidence, effect size moderate
  • Pelvic floor physiotherapy is suggested as an adjunct treatment option for FC in childrenconditional recommendation, overall low certainty evidence, effect size large
  • Abdominal transcutaneous electrical stimulation in combination with pelvic floor muscle exercises is suggested as a treatment option for FC in childrenconditional recommendation, overall moderate certainty evidence, effect size moderate
  • Percutaneous tibial nerve stimulation in combination with pelvic floor muscle exercises is suggested as a treatment option for FC in childrenconditional recommendation, overall moderate certainty evidence, effect size small

Good practice statements

  • The GDG recommends demystification, explanation, and guidance for toilet training (if developmentally appropriate) in the treatment of FC in children.
  • General statement regarding diet and physical activity: The GDG recommends a healthy, balanced diet with age‐appropriate water and fiber intake and normal physical activity in children with FC.
  • The GDG has made a GRADE recommendation about specific preparations of probiotics and synbiotics. Other pro‐ and synbiotic preparations do not have sufficient evidence at a strain level to support such recommendations due to issues with the precision of the data and methods of the studies
  • The GDG suggests that behavioral interventions should not be used in isolation but employed in select patients as an adjunct to other pharmacological therapies.
  • The GDG suggests not to use biofeedback alone, but to consider it as part of a wider strategy of pelvic floor physiotherapy.
  • The GDG recognizes the role of surgical interventions in a very select group of patients who are refractory to medical therapy. Prior to surgery, it is vital to ensure that the range of other treatments in this guideline have been carefully considered, a multi‐disciplinary team is involved, risks are weighed, appropriate investigations have been conducted, and that the postsurgical prognosis is discussed with the child and family.

Future guideline updates

  • The GDG recommends considering the option of a living review of the evidence, and consequently a living guideline, 137 something that was first widely used during COVID‐19. 138 Given the relatively small number of new trials each year, such an approach would provide an opportunity to promptly identify and address any significant changes in the overall certainty of evidence, and with that, potential recommendations. This concept should be promoted as a standard practice for the development of clinical guidelines in general.

Abstract

Objectives: Functional constipation (FC) is common in childhood, significantly impacting quality of life. Since the 2014 international guideline, new evidence has been published, and methods on making guidelines have developed. This treatment guideline for FC in children aged 0–18 years is a collaborative effort of the European and North American Societies for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN and NASPGHAN). The aim was to deliver evidence‐based recommendations applicable across all treatment settings worldwide and offer methodological guidance for future research.

Methods: The guideline development followed the “Grading of Recommendations Assessment, Development and Evaluation” (GRADE) approach. The Guideline Development Group (GDG) comprised clinical experts, representing ESPGHAN, NASPGHAN and Cochrane. Prospectively agreed‐upon treatments were formatted into “patient, intervention, comparison, outcome” questions. The GDG also determined decision thresholds for efficacy and safety outcomes through a Delphi process to support grading of the literature. Final recommendations were established by consensus voting, and a treatment algorithm was developed.

Results: A total of 102 original randomized controlled trials (RCTs) assessing treatment of FC in children aged 0–18 years were identified. Consensus was reached for 11 GRADE recommendations. Nineteen good practice statements were formulated, and guidance for future research methodology was proposed.

Conclusions: This guideline is the result of a collaborative effort between ESPGHAN and NASPGHAN on treatment options for FC. Systematic review of the evidence has revealed major evidence gaps for commonly used treatments for FC and highlights the need for large pediatric RCTs, particularly on treatment options with no evidence or only very low certainty evidence.

Contents of the original publication

The section headings of the original.

  • SUMMARY OF RECOMMENDATIONS
  • Pharmacological treatment: Disimpaction
  • Pharmacological maintenance treatment
  • Nonpharmacological maintenance treatment
  • Surgical therapy
  • INTRODUCTION
  • METHODS
  • Type of patients
  • Types of treatments
  • Outcomes
  • Thresholds for outcomes
  • Search strategy
  • Study selection, data collection, and analysis
  • Certainty of the evidence
  • Voting
  • Presentation of results
  • DEFINITIONS USED IN THIS GUIDELINE
  • Refractory/therapy‐resistant constipation
  • Fecal impaction
  • RESULTS
  • Pharmacological treatment: Disimpaction
  • Pharmacological treatment: Maintenance
  • Nonpharmacological maintenance treatment
  • Surgical therapy
  • Proposed not to make a recommendation
  • No consensus
  • FUTURE RESEARCH GOOD PRACTICE STATEMENT
  • Future guideline updates
  • DISCLAIMERS
  • Supporting information

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