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Pediatric Functional Constipation

Original Editor - Jennifer Withers, MSc Physiotherapy Student with Queens University. Completed page for 884 placement project.

Joint 884 placement clinical instructors - Laura Ritchie PT and Malini Dhandapani PT

Top Contributors - Jennifer Withers, Khloud Shreif, Kim Jackson and Lucinda hampton

Overview

Constipation can be broadly described as infrequent bowel movements of hard or dry stool. It can be further categorized into two subtypes Organic and Functional Constipation.

  • Organic constipation happens in 5% of pediatric cases, and is the result of structural, neurologic, toxic/metabolic or intestinal disorders.
  • Functional Constipation (FC), which is more common and involves unknown causes unlike organic constipation[1]and the most common functional gastrointestinal disorder in children. FC defined as a reduction in number of normal bowel movements, stool frequency, painful defecation, passage of hard stools, and/or sensation of incomplete evacuation of stools in child with no underlying pathology

ROME IV Diagnostic Criteria for FC:

The first ROME criteria was established to address various overlapping gastrointestinal issues in infants that were functional in nature. Later, in 2016, Rome IV was developed for diagnosing functional gastrointestinal disorders (FGIDs) and is now considered a helpful diagnostic tool for doctors. It highlights that while functional bowel disorders (functional diarrhea, functional constipation, IBS with predominant diarrhea [IBS-D], IBS with predominant constipation [IBS-C], and IBS with mixed bowel habits) have their own distinct diagnostic criteria, they are considered to be on a continuum rather than independent entities and may share similar treatment strategies[2]

Must include 2 or more of the following, occurring at least once per week for a minimum of 1 month with insufficient criteria for a diagnosis of irritable bowel syndrome (IBS)[3]or abdominal pain:

  • 2 or fewer defecations in the toilet per week in a child of a developmental age of at least 4 years
  • At least 1 episode of fecal incontinence per week
  • History of retentive posturing or excessive volitional stool retention
  • History of painful or hard bowel movements
  • Presence of a large fecal mass in the rectum
  • History of large diameter stools that can obstruct the toilet

After appropriate evaluation, the symptoms cannot be fully explained by another medical condition[3].

FC definition is not to be confused with:

Intractable constipation: Constipation not responding to treatment for at least 3 months[4]. For children with severe intractable constipation that is unresponsive to pharmacological management, referral to a specialized pediatric gastroenterologist is recommended. Surgery may be indicated as a last resort[5].

Fecal impaction: Is a hard mass in the lower abdomen identified during a physical exam, or a dilated rectum filled with a large amount of stool on rectal examination, or excessive stool in the distal colon viewed on an abdominal Xray[4]. Long term constipation can develop into fecal impaction. Fecal impaction can cause pain and vomiting, and may require emergency treatment or hospitalization[6].

Prevalence

The prevalence of pediatric FC ranges from 0.7-29.6%[7]. The wide range reported may be due to the use of different FC criteria and cultural influences[3]. In 2018, according to Rome III it was 9.5%, with Rome IV as the most recent tool used to assess FC it was 14.4%[8] that is also within the normal global range which indicate there is no difference in FC prevalence between using Rome III and Rome IV between . Peak incidence of constipation occurs at the time of toilet training, the median age of onset is approximately 2.3 years, or with age of the first time child go to school with no sex differences[9][3]. FC is distributed equally amongst different socio-economic backgrounds, with no relationship to family size, ordinal position of the child in the family, or parental age. Boys with constipation have higher rates of fecal incontinence compared to girls[3][10].

Impact

There are higher healthcare costs associated with children with constipation, mostly because of ambulatory care costs and, and also to a lesser degree related to hospitalizations and emergency room visits[11]. Constipation symptoms may lead to reduction in health-related quality of life, poor school performances and difficult social interactions at a crucial time when children are creating the foundations for learning and developing social skills[12]. Despite currently available treatment options, quality of care in FC is limited by lack of guidance for management, poorly defined condition characteristics, and insufficient data on drug and alternative therapies[13].

Pathological Process

Figure 1: Cycle of Constipation

Functional constipation in children is most often due to a history of painful defecation, or social reasons[14][1]. As a result a child will hold on to the stool, leading to greater absorption of water through the rectal mucosa and hardening of the stool, making it progressively more difficult to leave the body[3]. This leads to a vicious cycle of retention, in which the rectum becomes increasingly distended, resulting in overflow incontinence, loss of rectal sensation and eventually the loss of the normal urge to defecate (see figure 1)[3].

Children are prone to develop functional constipation during 3 periods:

  • After the introduction of cereals and solid food
  • Toilet training
  • When starting school[1]

Each of these milestones has the potential to convert defecation into an unpleasant experience[1].

In older children, diets low in fibre and high in dairy may lead to hard stools that are uncomfortable to pass and can cause anal fissures. Anal fissures cause pain with stool passage, leading to a similar vicious cycle of delayed bowel movements, resulting in harder stool that is more painful to pass[1][10].

Risk Factors

  • History of painful defecation
  • Genetic
  • Chronic constipation during infancy
  • Prematurity
  • Improper psychological development
  • Lowered muscle tone
  • Male sex (especially in early infancy and at pre-school age)
  • Cow's milk intolerance
  • Inadequate nutrition (diet poor in fibre, rich in fats and sugars, sweet drinks)
  • Low level of physical activity
  • Positive family history of FC
  • Sexual abuse
  • Psycho emotional background which can be commonly associated with stress, desire for control, fears and phobias surrounding changes in normal routine (examples including: toilet training, starting/changing nursery, family changes, etc.)
  • Children may also ignore the urge to have a bowel movement because their attention is focused on other more interesting activities[14][15].

Clinical Presentation

  • May exhibit unusual positions, for example toddlers arch their back, stand on their tiptoes, and wriggle or fidget, or they may squat
  • Abdominal distension and pain
  • Excessive postprandial fullness (child fees full and uncomfortable after normal sized meal)
  • Loss of appetite
  • Encopresis (fecal soiling by children past the age of toilet training)
  • Blood and mucus in the stool
  • Nausea
  • Vomiting
  • Abnormally slow weight gain[14]
  • Bowel dysfunction is also strongly associated with dysfunctional voiding[10][16]

Diagnostic Procedures

Medical History: Is the first step in diagnosing. Interview with parents should include factors such as age of onset, passage of first meconium, frequency and consistency of stools, abdominal pain, fecal incontinence, with holding behaviour, dietary history, vomiting, weight loss, stressful life events, neurodevelopmental delay, and inquiring about positive family history for gastrointestinal disease[17].

Physical Exam: Should include growth parameters, abdominal exam (looking for distension, tenderness, and palpable fecal masses), inspection of perianal region (examine for abnormally placed external sphincter, possible anal fistulas/fissures, inflammation, and signs indicating sexual abuse), and include an exam of lumbosacral region[17][14].

Rectal digital Exam: There is conflicting evidence on whether this is always necessary for diagnosing FC[17]. According to the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition, if only one of the ROME IV criteria is present and diagnosis of FC is uncertain, a rectal exam will be necessary[17]. The health provider completing the exam should take into consideration how functional constipation is often correlated with a strong fear of rectal examination[14].

Abdominal Imaging: Due to low correlation between clinical and radiological appearance, abdominal ultrasound is a more reliable alternative[17].

Anorectal Manometry: An anorectal manometry can be a useful screening tool in older children with untreatable constipation with suspicion of Hirschsprung disease[18]. The test can help with determining anal pressures, rectal sensation and potential absence of reflexes required for bowel movements.

Laboratory Testing: for chronic constipation cases, allergy testing may be required. Although the physiological process remains unclear, it is recommended that allergic inflammation of the internal sphincter may lead to increased anal pressure at rest[19].

Outcome Measures

Outcome Measure Description/Use
The Bristol Stool Scale or Amsterdam Infant Stool Scale Provides visuals that assist with reporting stool consistency[20]
Paediatric Quality of Life Inventory Review effects of functional constipation and fecal incontinence on quality of life (includes physical, psychosocial, and family functioning components)[21]
Childhood Bladder and Bowel Dysfunction Questionnaire Identifying frequency of symptoms with concomitant bowel and bladder disorders in children aged 5 to 12 years of age[22]
Dysfunctional Voiding Scoring System To quantify or grade the severity of abnormal voiding behaviours of children[23]
Bowel movement and symptom diary Helps to track after each toilet sit: date, stool description, sitting time, whether or not any stool came, whether or not underwear was clean or dirty, when/how much medication was given that day, and any pain or other symptoms[24]

Medical Management

Each management program must be adapted to meet the needs of the individual child and their family. Usually such a program consists of six steps, not necessarily in this order: the evacuation of fecal stones accumulated in the rectum (when necessary), a change in dietary habits, toilet training, behavioral treatment, family support, and pharmacotherapy[14].
The pharmacological management mainly consists disimpaction (of clearing of impaction stool), maintenance, and then gradual withdraw of the drug[25], polyethylene glycol is the first choice form of allatives.

The most effective and recommended method of treatment is non pharmacological intervention, which is safe, has no side effects, and brings long-term benefits. Unfortunately, some children fail to respond to this management and they require pharmacological treatment[14].

Non- Pharmacological Management[14] Pharmacological Management[25] [14]
Education Osmotic Laxatives
Behavioural Treatment Psychotherapy
Biofeedback Stimulants Laxatives (used when osmotic laxativealone

is not sufficient eg, senna, bisacodyl, sodium picosulfate)

Increase fibre intake Softeners
Increase fluid intake Bulk-producing Agents
Enema Lubricants (mineral oil known as liquid parafin)
Exercise Serotonin Receptor Agonists/ Prosecretory Agents.
Spasmolytics
Probiotics/ herbal medicine[26]

Mineral oil was advice not to be used for aged under 3 years, children with swallowing difficulties, and coagulation disorders[25].

Novel therapy (Serotonin Receptor Agonists/ Prosecretory Agents) is a new pharmacological management and still high-quality research on it[25].

Botulinum Toxin Injection (Botox)

It is considered the last option for management children with FC who don not respond to other treatments. It is injected in the internal anal sphincter, it's mechanism work through inhibiting the release of acetylcholine from neurons, resulting in partial chemical paralysis of the muscle and thereby relaxation of the injected anal sphincter muscles, this relaxing effect last for about 3–6 months. It was used for constipation in children wit Hirschsprung’s disease or internal anal sphincter achalasia[27], but there is no sufficient data about using Botox with functional constipation, but they thought it may help to break down the vicious cycle of stool withholding.

Physiotherapy

Pelvic Floor physiotherapy: Is able to provide specialized pelvic floor assessment and treatment, often complimentary to medical management by a patient's primary care provider. Depending on the patient and their family there are a variety educational and treatment tools that a physiotherapist will be able to provide. There is no universal standardized care plan. However, several have been proposed - using a combination of education, voiding and defecation diaries, toilet training, breathing and relaxation exercises and pelvic floor muscle training (involving exercises and biofeedback)[28].

Physiotherapy for FC focuses on improving coordination between the abdominal and pelvic floor musculature. The strength of physiotherapy is that physical exercises are combined with cognitive and behavioural elements, such as education and toilet training. There have been few trials completed researching the effects of physiotherapy in children with FC, although physiotherapy is expected to give optimal results in children with recent symptom onset[29].

Intervention Strategies Description
Dietary Modifications Juices like; apple, prune, and pear contain sorbitol, which can increase the frequency of stool and it's water content.

Adequate daily fiber and fluid intake can help, including fruits (apples with peels, raspberries, grapes, guava, pineapple, etc.), raw vegetables (broccoli, avocado, spinach, salads, etc.), whole grains, nuts, beans, and legumes[15]. In children older than 2 years of age, a minimal dietary fiber intake of “age plus 5 g” is usually recommended. However, a low-fiber diet may contribute to the development of constipation fibre intake above daily recommendations does not help with constipation[30].

Exercises 1. Increasing level of activity: regular physical activity promotes core strength, intestine motility, body awareness and can help reduce stress.
2. Incorporate exercises in a position that mimics the squatting posture when using the toilet. The squatting posture helps to relax some of the pelvic floor musculature and improve rectal-anal angle for stool elimination[31]. Activity in this position will depend on the child's comfort and tolerance, aim to gradually build up to 10 minutes including breaks.
  • Walking in Semi Squat position: Encourage their imaginations with this activity, have them pretend they are a bear or monster.
  • Invisible low chair yoga pose: instruct child to pretend that they are sitting on a low chair, aiming for 5 seconds. Consider having activity for them to do in lower position, for example each time they lower themselves into that position they get to blow bubbles, catch/throw a ball, etc.
  • Frog Squat: Have the child squat down to the floor with their feet apart. Have the child stay in this position for 5-10 seconds. Can have them practice their frog noises, then to break up the pose, have them jump like a frog where they can land and hold the pose again.
Biofeedback Children with FC may have unstable or tensed posturing on the toilet, which prevents the pelvic floor muscles from being able to relax properly[22]. Biofeedback techniques can assist with retraining pelvic floor strength, coordination and rectal sensation. Biofeedback techniques vary considerably among researchers. The most common techniques include anorectal manometry to display sphincter pressures or electromyography (EMG) to display electrical muscular activity[32].
Posture Review toilet posture: 1. Bottom at the back of the toilet seat, feet resting on a stool so that knees are apart and slightly higher than the hips 2. With a straight back, lean forward so the hips are bent 3. Let the tummy bulge forward between the thighs 4. Allow anus (or choose another word with the child such as door or gate, to help them visualize) . Keep breathing slowly and gently, waiting 6. Think about how they feel. Empty or full? Sit for at least 3 minutes[24].
Massage Abdominal "I Love U" Massage along the path of the large intestine: 1) moving from right to left, 2) form the letter "I" by stroking from right hip bone up to right rib cage using moderate pressure, 3) next form the "L" by stroking the letter "I" up to the right ribcage and then across the abdomen to the left ribcage, 4) Finally make the letter U by combing letters "I" and "L" and then finishing by stroking from left ribcage down to left hip bone. Can start with 5min of massage.
Equipment 1. Toilet needs to be positioned and at an appropriate level that the child feels comfortable, relaxed, and secure when using it. Consider a child sized toilet seat/insert[24]. Insert can have handles on the side, allows for better leverage when the child is getting ready to "push."
2. Secure stool to help provide stability and allow for better stool motility, stool should allow for knees to slightly higher than hip height[24].
Environment 1. Revamp bathroom to make it more comfortable for the child. Is it too dark? bad smells? cobwebs present[24]?
2. Consider making bathroom time more inviting, for example by adding child's favourite pictures[24], and allowing them to take their time in the bathroom.
3. Ensure toilet paper is within reach. If child is struggling with wiping consider flushable wet wipes[24].
Breath work The diaphragm and pelvic floor muscles work together to generate pressure, relax anal sphincters, and lengthen the pelvic floor muscles when having a bowel movement. These are often uncoordinated in children with constipation[22].
  • Deep belly breathing: practice smelling the flowers and blowing out the candles. Can also use other items to assist with breathing exercises such as a windmill toy, and when not on the toilet can practice blowing bubblies using a straw in a drink. Incorporate animal noises as needed (ssssss, grrrrrr) to prevent them from holding their breath while trying to defecate.
  • Progressive muscle relaxation: using imagery to help child visualize squeezing and relaxing certain muscles of the body. For example squeezing a lemon and dropping the lemon, "strong pose" showing off arm muscles and letting it go, squeezing through a tunnel or through a fence and coming out into the open on the other side, etc.
Behavioural Approach 1. Toileting routine - help to re-establish automatic signal to use the bathroom. This signal often starts when the stomach is stretched after mealtimes, 20-30min after a meal time is ideal for scheduling toilet use. Encourage the child to see for 3-5minutes[24]. Be sure to build this time into the routine, so that the child does not feel rushed.
2. Encourage participation - charts, stickers, filling out bowel diary, setting up reward system, and having them choose the games they want to complete while on the toilet (while ensuring that they are still able focus on defecation)[24]
Communication 1. Recording with bowel diary (see previous outcome measures): Helps to track after each toilet sit: date, stool description, sitting time, whether or not any stool came, whether or not underwear was clean or dirty, when/how much medication was given that day, and any pain or other symptoms[24].
2. Encopresis can be distressing for children and their families[33]. When coaching parents on how to react, encourage open communication with their child in terms of bathroom habits, symptoms and how to decrease any associated stress or anxiety with bathroom time. A couple of things for parents to keep in mind:
  • Be aware that overcoming constipation and fecal incontinence may be more of a process rather than involving a one time solution[33]
  • Important to create a nonthreatening and non-punitive environment[33].
  • Planning ahead can help prevent future stress and frustration, such as establishing a toilet routine, having a designated soiled clothing bin, packing an extra pair pants and underwear, etc[24].
  • Not overdoing the amount of attention given when the child has soiled themselves. Sometimes children will repeat behaviours to get attention[24].
  • Setting smaller goals, such as putting soiled clothing in designated area, going for a walk, filling out diary, etc. This can help the child to feel involved as well as increase their sense of control over FC[24].
Telerehabilitation home program Telerehabilitation home programs combined with laxatives were effective and demonstrated an improvement in all rome criteria and quality of life. The program consisted of:
  • Isometric training of the abdominal muscles: in first 3 months, 2 sequences of 8 contractions and relaxations, the next 3 months, 2 sequences of 12 contractions and relaxations
  • Breathing exercises: 2 sequences of 10 repetitions, with inhalation 6 to 8 seconds, hold breath 10 seconds, and exhalation 6 to 8 seconds
  • Abdominal massage: clockwise circular movement, starting with ascending to descending colon and each point taking about 1 minute[34].
Electrical stimulation and Transcutaneous Neuromodulation [35] Non-invasive intervention uses an electrical current to enhance peristalsis by stimulating nerve fibers and restoring neural balance[15].

Resources

Evidently Cochrane: Easing the Strain: put your feet up for constipation

MERCK MANUAL Constipation in Children

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 Pashankar DS. Childhood constipation: evaluation and management. Clinics in colon and rectal surgery. 2005 May;18(02):120-7.
  2. ↑ Schmulson MJ, Drossman DA. What is new in Rome IV. Journal of neurogastroenterology and motility. 2017 Apr;23(2):151.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 Hyams JS, Di Lorenzo C, Saps M, Shulman RJ, Staiano A, van Tilburg M. Childhood functional gastrointestinal disorders: child/adolescent. Gastroenterology. 2016 May 1;150(6):1456-68.
  4. ↑ 4.0 4.1 Tabbers MM, DiLorenzo C, Berger MY, Faure C, Langendam MW, Nurko S, Staiano A, Vandenplas Y, Benninga MA. Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. Journal of pediatric gastroenterology and nutrition. 2014 Feb 1;58(2):258-74.
  5. ↑ Koppen IJ, Lammers LA, Benninga MA, Tabbers MM. Management of functional constipation in children: therapy in practice. Pediatric Drugs. 2015 Oct 1;17(5):349-60.
  6. ↑ Harvard Health Publishing. Constipation and Impaction [Internet]. Harvard Health. 2016 [cited 2019Apr1]. Available from: https://www.health.harvard.edu/a_to_z/constipation-and-impaction-a-to-z
  7. ↑ Mugie SM, Benninga MA, Di Lorenzo C. Epidemiology of constipation in children and adults: a systematic review. Best practice & research Clinical gastroenterology. 2011 Feb 1;25(1):3-18.
  8. ↑ Tran DL, Sintusek P. Functional constipation in children: What physicians should know. World journal of gastroenterology. 2023 Feb 28;29(8):1261.
  9. ↑ Malowitz S, Green M, Karpinski A, Rosenberg A, Hyman PE. Age of onset of functional constipation. Journal of pediatric gastroenterology and nutrition. 2016 Apr 1;62(4):600-2.
  10. ↑ 10.0 10.1 10.2 Fedele F, Fioretti MT, Scarpato E, Martinelli M, Strisciuglio C, Miele E. The ten “hard” questions in pediatric functional constipation. Italian Journal of Pediatrics. 2024 Apr 8;50(1):64.
  11. ↑ Choung RS, Shah ND, Chitkara D, Branda ME, Van MT, Whitehead WE, Katusic SK, Talley NJ. Direct medical costs of constipation from childhood to early adulthood: a population-based birth cohort study. Journal of pediatric gastroenterology and nutrition. 2011 Jan;52(1):47-54.
  12. ↑ Bongers ME, van Dijk M, Benninga MA, Grootenhuis MA. Health related quality of life in children with constipation-associated fecal incontinence. The Journal of pediatrics. 2009 May 1;154(5):749-53.
  13. ↑ Sood M, Lichtlen P, Perez MC. Unmet Needs in Pediatric Functional Constipation. Clinical pediatrics. 2018 Nov;57(13):1489-95.
  14. ↑ 14.0 14.1 14.2 14.3 14.4 14.5 14.6 14.7 14.8 Gibas-Dorna M, Piątek J. Functional constipation in children–evaluation and management. Przeglad gastroenterologiczny. 2014;9(4):194.
  15. ↑ 15.0 15.1 15.2 Bashir SK, Khan MB. Pediatric Functional Constipation: A New Challenge. Advanced Gut & Microbiome Research. 2024;2024(1):5569563.
  16. ↑ Mulhem E, Khondoker F, Kandiah S. Constipation in children and adolescents: evaluation and treatment. American family physician. 2022 May;105(5):469-78.
  17. ↑ 17.0 17.1 17.2 17.3 17.4 Levy EI, Lemmens R, Vandenplas Y, Devreker T. Functional constipation in children: challenges and solutions. Pediatric health, medicine and therapeutics. 2017;8:19.
  18. ↑ Tabbers MM, DiLorenzo C, Berger MY, Faure C, Langendam MW, Nurko S, Staiano A, Vandenplas Y, Benninga MA. Evaluation and treatment of functional constipation in infants and children: evidence-based recommendations from ESPGHAN and NASPGHAN. Journal of pediatric gastroenterology and nutrition. 2014 Feb 1;58(2):258-74.
  19. ↑ Sopo SM, Arena R, Greco M, Bergamini M, Monaco S. Constipation and cow's milk allergy: a review of the literature. International archives of allergy and immunology. 2014;164(1):40-5.
  20. ↑ Kuizenga-Wessel S, Heckert SL, Tros W, van Etten-Jamaludin FS, Benninga MA, Tabbers MM. Reporting on outcome measures of functional constipation in children—a systematic review. Journal of pediatric gastroenterology and nutrition. 2016 Jun 1;62(6):840-6.
  21. ↑ Kovacic K, Sood MR, Mugie S, Di Lorenzo C, Nurko S, Heinz N, Ponnambalam A, Beesley C, Sanghavi R, Silverman AH. A multicenter study on childhood constipation and fecal incontinence: effects on quality of life. The Journal of pediatrics. 2015 Jun 1;166(6):1482-7.
  22. ↑ 22.0 22.1 22.2 van Engelenburg-van Lonkhuyzen ML, Bols EM, Bastiaenen CH, Benninga MA, de Bie RA. Childhood bladder and bowel dysfunction questionnaire: development, feasibility, and aspects of validity and reliability. Journal of pediatric gastroenterology and nutrition. 2017 Jun 1;64(6):911-7.
  23. ↑ Akbal CE, Genc Y, Burgu B, Ozden E, Tekgul S. Dysfunctional voiding and incontinence scoring system: quantitative evaluation of incontinence symptoms in pediatric population. The Journal of urology. 2005 Mar;173(3):969-73.
  24. ↑ 24.00 24.01 24.02 24.03 24.04 24.05 24.06 24.07 24.08 24.09 24.10 24.11 24.12 Royal Children's Hospital Foundation. Managing chronic constipation and soiling in children - conquering poos, a guide to parents & carers. 2012 [cited1 April 2019] Available from: http://www.brisbanenorthphn.org.au/content/Document/Pathways/pathways_parenthandout.pdf
  25. ↑ 25.0 25.1 25.2 25.3 de Geus A, Koppen IJ, Flint RB, Benninga MA, Tabbers MM. An update of pharmacological management in children with functional constipation. Pediatric Drugs. 2023 May;25(3):343-58.
  26. ↑ Kim E, Chang S, Nam J, Park N, Min SY. The synergistic effect of herbal medicine and probiotics in pediatric functional constipation: A systematic review and meta-analysis. Medicine. 2024 Feb 16;103(7):e36899.
  27. ↑ Baaleman DF, Hallagan A, Halleran DR, Orsagh-Yentis DK, Levitt MA, Wood RJ, Benninga MA, Bali N, Vaz KH, Yacob D, Di Lorenzo C. Anal botulinum toxin in children with Hirschsprung disease and functional constipation: a prospective cohort study. European Journal of Pediatric Surgery. 2023 Jun;33(03):241-8.
  28. ↑ van Engelenburg–van Lonkhuyzen ML, Bols EM, Benninga MA, Verwijs WA, Bluijssen NM, de Bie RA. The effect of pelvic physiotherapy on reduction of functional constipation in children: design of a multicentre randomised controlled trial. BMC pediatrics. 2013 Dec;13(1):112.
  29. ↑ van Summeren JJ, Holtman GA, Lisman-van Leeuwen Y, Louer LE, van Ulsen-Rust AH, Vermeulen KM, Kollen BJ, Dekker JH, Berger MY. Physiotherapy plus conventional treatment versus conventional treatment only in the treatment of functional constipation in children: design of a randomized controlled trial and cost-effectiveness study in primary care. BMC pediatrics. 2018 Dec;18(1):249.
  30. ↑ Southwell BR. Treatment of childhood constipation: a synthesis of systematic reviews and meta-analyses. Expert review of gastroenterology & hepatology. 2020 Mar 3;14(3):163-74.
  31. ↑ Sikirov BA. Primary constipation: an underlying mechanism. Medical hypotheses. 1989 Feb 1;28(2):71-3.
  32. ↑ Lee HJ, Jung KW, Myung SJ. Technique of functional and motility test: how to perform biofeedback for constipation and fecal incontinence. Journal of neurogastroenterology and motility. 2013 Oct;19(4):532.
  33. ↑ 33.0 33.1 33.2 Castiglia PT. Encopresis. Journal of Pediatric Health Care. 1987 Nov 1;1(6):335-7.
  34. ↑ Soliman A, AboAli SE, Abdel Karim AE, Elsamahy SA, Hasan J, Hassan BA, Mohammed AH. Effect of adding telerehabilitation home program to pharmaceutical treatment on the symptoms and the quality of life in children with functional constipation: a randomized controlled trial. European Journal of Pediatrics. 2024 Sep;183(9):3943-58.
  35. ↑ Iacona R, Ramage L, Malakounides G. Current state of neuromodulation for constipation and fecal incontinence in children: a systematic review. European Journal of Pediatric Surgery. 2019 Dec;29(06):495-503.
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