Today we are showcasing key highlights from the American Gastroenterological Association (AGA) and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) clinical care pathway, Pediatric Functional Constipation. Functional constipation (FP) is a prevalent condition in children that can significantly impact quality of life. This AGA/NASPGHAN clinical care pathway provides a consensus-driven approach to support clinical decision making for pediatric providers in the diagnosis, evaluation, treatment, and transition to adult care for FC.
In today’s spotlight, we will go over key highlights from the pathway. Refer to the full-text version for the most thorough explanation of each highlight, including diagnostic approaches, treatment interventions, guidance for special populations, and more.
Key Highlights from the 2026 Pediatric Functional Constipation Clinical Care Pathway
Diagnostic Studies
Abdominal X-ray: There is no evidence to support routine use of abdominal x-ray in the management and diagnosis of functional constipation (FC). Abdominal X-ray has poor diagnostic accuracy, with no correlation between symptoms and fecal load, low intra- and interobserver reliability, and poor sensitivity and specificity.
Colonic Transit Studies: Colonic transit has limited value in predicting outcomes as most patients with FC have normal transit, routine use is not recommended.
Contrast Enema: Contrast enema has been used to screen for Hirschsprung’s disease (HD), but a normal study does not rule it out. Evaluation of colonic diameter has not been associated with outcomes.
Anorectal Manometry: Anorectal manometry allows assessment of anal sphincter function and length. The main indication is to evaluate the presence of the rectoanal inhibitory reflex, to screen for HD or internal anal sphincter achalasia, and in appropriate patients to assess for dyssynergic defecation. In children with FC, anorectal manometry has not been shown to add clinical value.
Colonic Manometry: Colonic manometry (CM) is the test of choice to evaluate colonic motility function. CM can help identify colonic dysmotility and has been helpful in selecting patients for surgical interventions, but not medical therapy. Its use should be limited to patients being considered for surgery.
Treatment
Treatment of FC in children begins with changes in diet, lifestyle, and activity and may progress into medications, and then more invasive treatments if necessary.
For behavioral interventions, pelvic floor physical therapy and biofeedback has not been proven to be effective but may be recommended for those with proven dyssynergic defecation. In certain cases, comprehensive treatment may require a multidisciplinary team including a pediatric mental health professional, ideally a gastrointestinal psychologist or other pediatric mental health clinician with expertise in gastrointestinal conditions. Enhanced toilet training is the only behavioral intervention with empirical evidence for toileting and fecal incontinence.
Medical treatment includes three phases: identification and treatment of fecal impaction, maintenance therapy, and eventual withdrawal of medical treatment. Despite the lack of a clear and accepted definition of fecal impaction, it is important to evaluate and treat fecal impactions prior to maintenance therapy as this leads to better outcomes.
Surgical interventions are reserved for pediatric patients who fail adequate medical and behavioral therapy, and a multidisciplinary evaluation is recommended for those considered for surgery.
Transition of Care
Scientific societies recommend education on transition of care from children into adulthood into the training of pediatric and adult gastroenterologists. The following are recommended steps to support the management approach to achieve a successful transition process:
- Educating health care administrators of the importance of transition of care.
- Establishing current procedural terminology that reflects the complexity of the process.
- Educating pediatric and adult gastroenterologists on the mutually applicable diagnostic criteria, testing and management approaches.
- Familiarizing adult providers with the care of young adults and their parents.
- Harmonizing diagnostic criteria and treatment in pediatric and adult patients.
- Common diagnostic criteria for FC would allow combined meta-analysis, systematic reviews, and clinical trials with participants of different age groups as well as longitudinal studies.
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