Abstract

Functional constipation (FC) is a common condition in children that can significantly affect their quality of life and often requires long-term management. Given the multifactorial nature of FC, treatment should be personalised and include both non-pharmacological and pharmacological approaches.1–3 This review analyses the efficacy and safety of non-pharmacological interventions in the management of childhood FC. Electronic searches were conducted in PubMed, MEDLINE, Embase, and PsycINFO up to March 2025 for randomised controlled trials (RCTs) including children aged 0-18 years with FC and treated with non-pharmacological interventions, compared to placebo, no treatment or any other intervention. Primary outcomes were treatment success, defecation frequency and withdrawals due to adverse events. The certainty of the evidence was assessed using the GRADE framework. We included a total of 93 RCTs, comprising 7,787 children (50.4% female). We investigated 47 interventions, including dietary, psycho-educational, physiotherapy, complementary and alternative medicine, and electrical stimulation. Abdominal transcutaneous electrical stimulation (ATES) combined with pelvic floor muscle exercises (PFME) probably improves treatment success and defecation frequency compared with PFME alone (RR 1.75, 95% CI 1.25 to 2.44; MD 1.85, 95% CI 1.28 to 2.43; moderate certainty). Percutaneous tibial nerve stimulation (PTNS) associated to PFME may improve treatment success (RR 1.73, 95% CI 1.08 to 2.77; low certainty) and probably increase defecation frequency (MD 1.82, 95% CI 0.82 to 2.82; moderate certainty). Behavioural therapy combined with PEG may not improve treatment success (RR 0.83, 95% CI 0.62 to 1.12; low certainty) and probably reduces defecation frequency (MD -1.80, 95% CI -2.88 to -0.72; moderate certainty). It is uncertain if there is any difference in defecation frequency when probiotics are added to laxatives compared to laxatives alone (MD: 0.12, 95% CI -0.09 to 0.34; low certainty). Cow’s milk free diet (CMFD) in addition to PEG may improve defecation frequency when compared to normal diet in addition to PEG (RR: 1.34, 95% CI 1.15 to 1.57; low certainty). Some non-pharmacological treatments for childhood FC demonstrate beneficial effects and may be considered as part of management. Future RCTs should focus on improving methodological rigor.