2026 ESPGHAN/NASPGHAN Guideline: Treatment of Functional Constipation in Children Aged 0–18 Years

Full title: ESPGHAN/NASPGHAN Guidelines for Treatment of Functional Constipation in Children 0–18 Years Issued by: European Society for Paediatric Gastroenterology, Hepatology and Nutrition & North American Society for Pediatric Gastroenterology, Hepatology and Nutrition Published: May 2026, Journal of Pediatric Gastroenterology and Nutrition Method: GRADE framework; updated from the 2014 guideline, covering infants, preschool, school-age children and adolescents.

Core principle: Functional constipation (FC) is a clinical diagnosis based on Rome IV criteria. Management has three sequential phases: disimpaction, maintenance therapy, and slow withdrawal of laxatives. Patient/family education, toilet behaviour training and lifestyle advice are foundational for all ages. Polyethylene glycol (PEG) is the first-line pharmacological agent for both disimpaction and maintenance.

1. Diagnosis and initial assessment

• Diagnosis relies on history and physical examination. Routine abdominal radiograph, colonic transit study, rectal ultrasound are not recommended to confirm FC.
• Red flags requiring further investigation: weight loss, faltering growth, rectal bleeding, severe abdominal distension, perianal anomalies, delayed passage of meconium, family history of Hirschsprung disease.
• Faecal incontinence (encopresis) in FC is overflow incontinence, not a primary behavioural problem. This must be explained to caregivers.

2. Non-pharmacological therapy (base for all patients)

1. Education: Explain withholding mechanism, overflow soiling, chronic nature and high relapse risk.
2. Diet: Normal age-appropriate fibre and fluid intake. High fibre supplementation is not routinely recommended for treatment of FC.
3. Physical activity: Encourage regular daily movement.
4. Toileting training: For developmental age ≥4 years: sit on toilet 5–10 minutes after meals, foot support, reward system; avoid punishment for accidents.
5. Stool diary: Track bowel frequency, stool consistency and incontinence episodes to monitor response.

3. Phase 1: Faecal disimpaction

✅ First-line: PEG (with/without electrolytes), dose 1–1.5 g/kg/day for 3–6 consecutive days. ✅ Alternative: enemas, if PEG unavailable; oral route preferred by most families.

Infants: glycerin suppositories may be used for disimpaction; enemas are generally avoided in infants.

4. Phase 2: Maintenance laxative treatment

✅ Strong recommendation: PEG (with/without electrolytes) is first-line maintenance; starting dose 0.2–0.8 g/kg/day, titrate to achieve soft, easy-to-pass stool once daily. 🟡 Conditional recommendations:

• Magnesium hydroxide: optional alternative (low certainty evidence)
• Linaclotide: suggested for children ≥6 years with refractory FC (small benefit) ❌ Not suggested: prucalopride for paediatric FC; enemas as routine add-on during maintenance.

Good practice statements: Lactulose, bisacodyl, senna, sodium picosulfate, liquid paraffin may be used as alternatives when PEG is unavailable or not tolerated.

Minimum maintenance duration: at least 2 months, and continue for at least 1 full month after complete symptom resolution. Early stopping is the top cause of relapse.

5. Phase 3: Withdrawal of laxatives

Gradual tapering over weeks/months after sustained symptom control, combined with continued behavioural and diet support. Relapse after discontinuation is common; reintroduce maintenance laxatives if symptoms recur.

6. Refractory functional constipation

Definition: symptoms persist after adequate disimpaction + optimised maintenance therapy for ≥3 months. Interventions (conditional):

• Abdominal transcutaneous electrical stimulation combined with pelvic floor training
• Transcutaneous tibial nerve stimulation combined with pelvic floor training
• Transanal irrigation
• Antegrade continence enemas / surgery: reserved for highly selected severe refractory cases after full MDT evaluation.

7. Age-specific considerations

Infants (<12 months)

• PEG / lactulose are preferred osmotic agents.
• Sorbitol-containing juices (prune, pear, apple) may be tried for mild symptoms.
• Stimulant laxatives and mineral oil are avoided in infants.

Adolescents

• Address psychological distress, school toileting barriers, stigma of soiling; transition plan to adult gastroenterology for persistent cases.

8. Key warnings & common pitfalls

❌ Pitfall 1: Prescribe high-fibre diet alone as treatment for established FC ✅ Correction: Adequate laxative therapy is required; extra fibre is not effective as monotherapy.

❌ Pitfall 2: Skip disimpaction and start only maintenance laxatives ✅ Correction: Undetected faecal impaction is the most common reason for treatment failure.

❌ Pitfall 3: Stop laxatives immediately once symptoms improve ✅ Correction: Must maintain for ≥1 month after symptoms resolve then taper; early cessation leads to high relapse rate (>50%).

❌ Pitfall 4: Use abdominal X-ray routinely to diagnose constipation ✅ Correction: FC is clinical diagnosis; imaging only for suspected alternative pathology.

❌ Pitfall 5: Faecal soiling = behavioural problem ✅ Correction: Overflow incontinence from impaction; behavioural measures alone will not resolve it.

9. Guideline Summary

The 2026 ESPGHAN/NASPGHAN guideline updates the stepped management of paediatric functional constipation across 0–18 years. The three-phase framework is disimpaction → maintenance → slow laxative withdrawal. PEG is strongly recommended as first-line for both disimpaction and maintenance. Non-pharmacological strategies (education, toileting training, normal fibre/fluid) are foundational adjuncts, not substitutes for laxatives. Refractory cases may consider neuromodulation or transanal irrigation. Routine imaging is not required for uncomplicated FC. Caregiver education on overflow incontinence and long treatment course is critical to reduce relapse.