The ten "hard" questions in pediatric functional constipation

Functional constipation is a common problem in childhood and has a great impact on social, physical, and emotional functioning of affected children and their caregivers. No organic cause of the constipation can be found in approximately 95% of children, defining the "so-called" chronic functional constipation. Its prevalence has been reported to range from 0.7 to 29.6%, with a median of 12%. The diagnosis of functional constipation is exclusively clinical based on the pediatric diagnostic Rome criteria for functional gastrointestinal disorders and does not routinely require laboratory and/or radiological investigations. In case of alarm signs and symptoms that may suggest organic diseases, further investigations can be required. The therapeutic management is based on non-pharmacological and pharmacological approaches. Education, demystification of constipation and reward-based toilet training represent the cornerstones of nonpharmacological management. Disimpaction, maintenance treatment and weaning of medication are all elements of pharmacological treatment. Osmotic laxatives, mainly polyethylene glycol (PEG), are considered the first-choice laxative for both disimpaction and maintenance treatment. The aim of this review is to provide pediatric gastroenterologists with a practical tool to support the clinical and therapeutic management of children and adolescents affected by chronic functional constipation. 1. FC should be diagnosed using Rome IV criteria.2. FC is the most common functional gastrointestinal disorder in children.3. Pathophysiology of FC is multifactorial but the stool withholding behavior seems to be the main etiological agent.4. FC is the most frequent cause of abdominal pain and fecal incontinence in childhood.5. In the presence of alarm symptoms or in case of failure of conventional treatments, further investigations may be recommended.6. When education, lifestyle, diet and toilet training are not sufficient in the management of FC, the next step is the pharmacological treatment.7. Polyethylene glycol (PEG) is the first choice in the treatment of FC in children, both for disimpaction and for maintenance treatment.8. Maintenance treatment should continue for at least 2 months. After resolution of constipation symptoms, treatment should be decreased gradually.9. A normal physical activity, a normal fiber and fluid intake is recommended in children with FC.10. A strict follow-up is highly recommended to avoid persistence of FC symptoms.