Childhood constipation is a common condition affecting up to 30% of all children at any one time with 95% of cases being identified as functional (Levy et al, 2017), that is constipation that cannot be explained by structural or biochemical findings (Hyams et al, 2016).
 
Constipation often starts with the passage of a stool which is uncomfortable or painful to pass, leading to stool withholding. Withholding results in more water being absorbed in the colon, leading to larger firmer stools which are difficult to pass and perpetuating the cycle. As a result, any constipation should always be treated as it will not get better on its own and prolonged untreated constipation can lead to faecal impaction and overflow soiling (Figure 1). 
 

Management and treatment

The management of constipation should be holistic, including education, behaviour modifications, dietary interventions and laxatives, with disimpaction if necessary, and should be individualised to each child. Early intervention is important as early evaluation and treatment can have a positive impact on the child’s overall health and wellbeing and can prevent the development of associated comorbidities (Bashir and Khan, 2024).
 

Education, behaviour modifications and lifestyle changes

It is important that families are made aware that constipation is not a benign condition and that it should always be treated appropriately. Holistic lifestyle management and the role of laxatives should be explained, including the difference between stool softeners and stimulants and how each one works. The Bristol Stool Form Chart should be discussed and the family advised how to adjust any laxatives if necessary to produce the desired stool consistency. To help families manage the constipation more effectively at home Reeves et al (2021) have developed a pictogram-based constipation action plan (Figure 2). The plan guides families through the stepwise approach to addressing constipation, based on the child's observed signs and symptoms.

The optimum sitting position on the potty and toilet should be explained so that the child is able to sit in a comfortable relaxed position with their feet flat, and on a step or stool if necessary, with their legs bent and their knees higher than the hips (Reeves et al, 2025).

Figure 1. The constipation–pain–withholding cycle. Adapted from The Children’s Mercy Hospital (2022). 

Encouraging the child to sit on a potty or toilet around 15 minutes or so after meals will also take advantage of the gastrocolic reflex. If there is any resistance to sitting on the potty or toilet then the use of incentives and rewards with lots of positive reinforcement may help.
 

Physical exercise

Lack of physical exercise is often cited as a contributory factor to the development of constipation (Seidenfaden et al, 2018). A systematic review by Adil et al (2024) did not find clear evidence that insufficient physical activity is the main contributing factor to functional constipation in children. However, they noted that the absence of strong evidence does not rule out a possible link and recommended further rigorous research on the topic.

A systematic review reported that moderate exercise is beneficial in helping the management of constipation (Al-Beltagi et al, 2025). The review concluded that moderate exercise positively influences bowel function through several mechanisms. First, physical activity stimulates intestinal motility by increasing the activity of the smooth muscles in the gastrointestinal tract, facilitating the movement of stool through the colon. Aerobic exercises, such as walking, jogging, and swimming, are cited as particularly effective in speeding up colonic transit time, which can help reduce the time stool spends in the colon, preventing excessive water absorption and hardening of the stool.
 

Massage

Abdominal massage has been identified as an adjunctive therapy that may enhance colonic motility and facilitate bowel movements. The proposed physiological mechanism involves stimulation of the parasympathetic nervous system and vagal activity, which can improve colonic transit and reduce faecal retention by increasing comfort during defecation (Doğan et al, 2022). Additionally, they felt that this intervention may help to reduce reliance on long-term, high-dose laxatives.

Malekiantaghi et al (2025) carried out a randomised controlled trial, which included 61 children aged 4–10 years, to evaluate the effectiveness of abdominal massage as an adjunctive therapy to laxatives. They concluded that a 12-session programme of abdominal massage therapy appears to be an effective adjunct to standard pharmacological therapy for alleviating constipation-related symptoms in children.

A literature review carried out by Liu et al (2021) assessed the effectiveness of traditional Chinese infant massage on the frequency and consistency of defaecation and its safety in the treatment of infant functional constipation. They concluded that infant massage increased the frequency of defaecation and reduced the symptoms of constipation in children suffering from functional constipation. 
 

Dietary interventions 

Fibre 

Although increasing intake of dietary fibre is often the first advice given for the treatment of constipation, a study by Tappin et al (2020) concluded that lack of dietary fibre was not the main cause of constipation in children and that increasing fibre intake alone was not effective in resolving constipation. This reflects the advice given by the National Institute of Health and Care Excellence (NICE) regarding the treatment of childhood constipation. The NICE guideline CG99 (2017) states ‘Do not use dietary interventions alone as first-line treatment for idiopathic constipation’. So, if constipation is established, any dietary modifications should not be used as the primary treatment option but as adjunctive therapy alongside laxatives. However, dietary modification should continue once the constipation has been resolved, to help prevent any future relapse.

Figure 2. The Uniformed Services Constipation Action Plan. From Reeves et al (2021). 

Many foods contain both soluble and insoluble fibre but foods with higher levels of soluble fibre include oats, apples, citrus fruits, and sweet potato. Food that contain insoluble fibre include beans, nuts, wheat bran, vegetables such as green beans and broccoli, and fruits with the skin on. Clinical experience has shown that foods rich in soluble fibre may be more beneficial for helping constipation than those that are rich in insoluble fibre. As it is not broken down, insoluble fibre tends to make the stool bulkier and heavier and an excess may not be beneficial, particularly if slow transit constipation is present (Erdogan et al, 2016). In some cases, it can make constipation worse. Soluble fibre, on the other hand, turns into a gel-like substance in the gut which retains water and keeps the stools soft.

A multi-centre randomised controlled trial by Gearry et al (2023) that involved adults eating two kiwi fruits a day resulted in softer stools and improved defaecation (stools that were easier to pass). Kiwis contain soluble fibre. Although no similar studies with kiwis could be found in children, ensuring a healthy ‘rainbow’ diet including such things as kiwis, has been found to be beneficial (Hozyasz, 2023). Although there is no recommended daily amount of fibre intake for children (unlike for adults) the suggested amount can be calculated by adding 5 g to the child's age in years (Dierkes et al, 2023).

Sorbitol is a water-soluble compound that occurs naturally in many fruits and vegetables. It is a type of carbohydrate and it helps keep the stool soft by drawing water into the large bowel thereby helping to prevent constipation. Sorbitol is found in dried fruits (particularly prunes), fruit with stones and in apples and pears. So, encouraging sorbitol-rich fruits in a child’s diet will help soften the stools and ease defecation (Ellis and Meadows, 2002; Koyama et al, 2022).

The addition of probiotics is also recommended. Several studies reported significant improvement in stool frequency and consistency following the administration of probiotics (Chen et al, 2024; Narula Khanna et al, 2025). A network meta-analysis of randomised controlled trials carried out by Yang et al (2024) looked at the addition of probiotics to laxative therapy. They reported that laxative therapy alone often has no more than a 60% success rate in managing paediatric functional constipation but that the addition of probiotics alongside laxative treatments resulted in improvement in stool frequency and consistency. The authors concluded that their findings support the use of a combination of probiotics and laxatives in managing paediatric functional constipation, provided no contraindications are present.
 

Fluids 

From clinical experience many children do not drink enough and increasing the fluid intake to recommended daily amounts is advised. However, although low fluid intake may contribute to the development of constipation, increasing fluid intake above usual daily recommendations has not been shown to improve constipation in children (Mulhem et al, 2022). 
 

Laxatives 

Once constipation is diagnosed laxative treatment should always be started. This consists of two or three phases: disimpaction if necessary, maintenance treatment and weaning off the medication if possible. However, there should never be a rush to wean off laxatives and it should always be done gradually in response to the frequency and consistency of the child’s stools.

Macrogols should be used as first-line treatments. A meta-analysis by Lee-Robichaud et al (2010) looked at studies including children from the age of 3 months to adults aged 70 years. They found that polyethylene glycol (macrogols) is better than lactulose in terms of outcomes of stool frequency per week, form of stool and relief of abdominal pain. They concluded that polyethylene glycol should be used in preference to lactulose in the treatment of constipation. This finding is supported by a more recent study by Sadeghvand et al (2025) which looked at the treatment of constipation in children with cerebral palsy. They concluded that polyethylene glycol appeared to be more effective than lactulose in managing the constipation. However, lactulose can be used as second line if macrogols are not tolerated. 

For children presenting with faecal impaction, removing the hard stool from the colon is the first step in treating constipation. Faecal impaction can be diagnosed primarily by the history of stool frequency and consistency and the presence of overflow soiling. A faecal mass may be felt during an abdominal examination, but it may not always be palpable. A rectal examination is rarely indicated and if performed it should only be undertaken by a healthcare professional competent to do so (NICE, 2017). If carried out hard stool would be found in a dilated rectum.

During the disimpaction process the child should be kept under review to evaluate its effectiveness. In some refractory cases the process may need to be repeated, or a stimulant laxative added. If necessary, rectal administration may be considered to help facilitate disimpaction. Glycerine suppositories are safe and effective in infants and bisacodyl suppositories for older children (Leung and Hon, 2021). Enemas may also be considered in some cases and are as effective as polyethylene glycol for disimpaction (de Geus et al, 2023). However, the rectal route is not tolerated by all children so should only be considered if the oral route fails and the child and family consent (NICE, 2017). Phosphate enemas should only be administered under specialist supervision and are contraindicated in children with Hirschsprung’s disease because of the risk of developing hyperphosphataemia (Tabbers et al, 2014). 

Maintenance therapy should be introduced following disimpaction or started straight away if there is no impaction. This should be continued for several weeks (or even months) after a good response to treatment. Medications should be weaned gradually and may need to be continued for months or years in some cases. 

If functional constipation develops before the child is toilet trained, maintenance therapy should be continued until after toilet training is achieved as potty training can trigger the development of constipation. Relapses can happen and should be treated with maintenance therapy or disimpaction therapy when appropriate.

In some cases, the use of stool softeners alone may fail to resolve the constipation, and a stimulant laxative may be necessary (de Geus et al, 2023). Stimulant laxatives enhance colonic peristalsis by stimulating the enteric nervous system which helps facilitate evacuation of the softened stool.

The informed use of unlicensed medicines or of licensed medicines for unlicensed applications (‘off-label’ use) is often necessary in paediatric practice and that includes the treatment of constipation. The NICE (2025) clinical knowledge summaries have recently updated their prescribing recommendations for the treatment of constipation in children and young people. This is a useful tool for practitioners to use in determining recommended laxatives and the dose of laxatives for the child’s age. 
 

Refractory constipation 

The majority of children with functional constipation, with or without associated soiling, tend to respond to conventional standard treatment that includes dietary, lifestyle and laxative interventions. However, if children and young people fail to respond to initial treatment within 3 months, the NICE (2017) guideline on childhood constipation recommends that they should be referred on to a practitioner with expertise in the problem, such as a specialist paediatric nurse, a paediatrician or paediatric gastroenterologist. 

Although not universally available, other more specialist adjunctive treatment options may be considered. Chase and Shields (2011) carried out a systematic review to establish the efficacy of non-pharmacological, non-surgical and non-behavioural treatments of functional chronic constipation in children. They found that the efficacy of chiropractic, reflexology, acupuncture or transcutaneous electrical stimulation had not been established at that time. They were aware that such interventions are identified as treatment modalities, and that there was some preliminary evidence to suggest that they deserve further investigation. They highlight acupuncture and transcutaneous stimulation as being of particular interest.

Wang et al (2020) carried out a more recent systematic review and meta-analysis of the use of acupuncture in the treatment of functional constipation. They suggested that acupuncture is safe and effective for functional constipation, especially in terms of increased stool frequency and improved constipation symptoms, stool formation, and quality of life. They emphasised that high quality randomised controlled trials are still needed to provide evidence to support these conclusions.

A systematic review undertaken by Iacona et al (2019) looked at the use of neuromodulation in the treatment of constipation in children. The papers they reviewed included a range of neuromodulation modalities including implantable sacral nerve modulation, transcutaneous tibial nerve stimulation, transcutaneous sacral nerve modulation, and transcutaneous interferential sacral nerve stimulation. They concluded that neuromodulation is a promising tool in the management of constipation that is refractory to laxative treatment and faecal incontinence in children, providing good results with no complications.

Transcutaneous posterior tibial nerve stimulation involves electrical stimulation at the level of the ankle via electrodes fixed to the skin. It is a minimally invasive, easy-to-apply technique that aims to improve constipation symptoms in children by stimulating the sacral nerves. Rego et al (2024) evaluated the effectiveness of transcutaneous posterior tibial nerve stimulation as an adjuvant treatment for intractable constipation in a study involving 28 children with a median age of 11 years. The children completed between 4 and 8 weeks of treatment which brought positive results through a significant improvement in defaecation, intestinal symptoms, and health-related quality of life. The authors concluded that transcutaneous posterior tibial nerve stimulation is an effective adjuvant treatment for intractable functional constipation, improving bowel function and quality of life.

Biofeedback is a behavioural therapy which, by means of giving patient feedback, teaches the proper control over actions of, for example, certain muscles that have a role in defaecation. Although biofeedback is not currently available in all centres, it has been used to improve outcomes in cases of constipation and soiling that is refractory to standard dietary and medical treatments. A retrospective study of biofeedback therapy involving 44 children, carried out by Jarzebicka et al (2016), reported 86% clinical improvement. They concluded that biofeedback therapy has high clinical efficacy and recommended that it should be used as a treatment method in children in whom dietary and pharmacological procedures fail to resolve the constipation.
 

Conclusions 

Constipation in children is often a complex disorder that requires a multifaceted individualised approach for effective management. The traditional approach of increasing fluids and fibre intake while also encouraging exercise are helpful but not effective treatments on their own. They should be included as part of adjunctive interventions alongside laxatives.

A well-defined and organised follow-up plan is fundamental to continually evaluating the effectiveness of any treatment. Follow-up appointments should be arranged at predetermined intervals to assess the child’s progress and implement modifications as needed. 

Furthermore, parents should be empowered to manage their child’s constipation effectively. For example, they should be given clear criteria for adjusting laxative dosages in response to the frequency and consistency of their child’s stools. They should also have a contact number for their healthcare professional so they can discuss any concerns they may have or the need for additional treatments if symptoms persist.

It is equally important to establish definitive guidelines for timely referral to specialists, particularly if the constipation remains unresolved, despite optimal management, or if there are complicating factors such as psychosocial concerns or coexisting medical conditions. Timely, appropriate treatment interventions will reduce the risk of comorbidities and improve the child’s quality of life and overall wellbeing.