Pediatric constipation is commonly encountered by medical practitioners.1 Approximately 3% of children who visited a pediatric clinic have constipation, and 25% of these children are referred to pediatric gastroenterology clinics.2 A study from a tertiary center for pediatric gastroenterology in the Netherlands showed an even higher rate (45%) of consults were due to defecation disorders.3 The symptoms of pediatric constipation can decrease the quality of life and negatively affect childhood development.13

The majority of children with constipation do not have an underlying medical disease.4 The ROME III criteria, which defined and presented the diagnostic criteria for pediatric functional constipation (FC), was updated in 2016 to the ROME IV criteria; this update decreased the duration of symptoms from 2 months to 1 month for children aged ≥ 4 years.5

We distributed a questionnaire throughout Korea to investigate the real-world practice patterns of pediatricians for FC. In addition, we compared the differences in clinical practice between general pediatricians and pediatric gastroenterologists (PGs).

A total of 239 out of 500 (47.8%) members of the Korean Society of Pediatric Gastroenterology, Hepatology, and Nutrition (KSPGHAN) responded to the questionnaire. The study population was pediatricians who manage children with FC aged 0–18 years.

The survey was anonymized and conducted for one week using an online mobile phone application. The survey had 40 questions that took an average of 12 minutes to complete on the following subjects. It had been modified after a pilot study. The awareness and application of the definition for pediatric FC, use of various diagnostic methods, management duration and follow-up patterns, rate of relapse, and pharmacologic and non-pharmacologic treatment. We used the definition of FC from ROME IV criteria that required ≥ 2 of the following symptoms or signs without organic cause: ≤ 2 defecations per week, ≥ 1 episode of incontinence per week, history of excessive stool retention, history of painful or hard bowel movements, presence of a large fecal mass in the rectum, and history of large-diameter stools that could obstruct the toilet. In addition, the duration of symptoms should be ≥ 1 month.67 We collected information whether they perform perianal examination, digital rectal examination (DRE), imaging studies and laboratory investigation. We collected information on disimpaction practices, and pharmacologic and non-pharmacologic treatments. The treatments were divided into two groups: age ≥ 1-year and age < 1-year. In the age ≥ 1-year group, we included the medications polyethylene glycogen (PEG) 4000, PEG 3350, lactulose, magnesium, lactitol, and probiotics. In the age < 1-year group, we included formula changes, PEG 4000, PEG 3350, lactulose, and probiotics. We asked about diet modification, toilet training, defecation diaries, and multidisciplinary approaches that included dieticians and pediatric psychologists. In addition, we asked about the treatment methods for encopresis.

We assessed the clinical practice patterns for pediatric FC, and we assessed if there were differences between PGs and general pediatricians.

Descriptive statistics for continuous variables were reported as the mean ± standard deviation, and categorical variables were reported using counts and percentages. The χ² test, Fisher's exact test, or Student's t-test were used to investigate the significance of differences between the PGs and general pediatricians, as appropriate for the data type. A P value < 0.05 was considered statistically significant. Statistical analyses were performed using SPSS version 20.0.1 (SPSS Inc, Chicago, IL, USA).

We found discrepancies in our study between actual practice and the ROME IV criteria, and between PGs and general pediatricians. To become a PG in Korea, a pediatrician must have specific training and clinical experience and pass a license examination.

A previous study reported that less than half of the surveyed pediatricians in the Mediterranean area used the ROME criteria for functional gastrointestinal disorders; in addition, most pediatricians were using the symptoms reported by parents to diagnose FC, and those who were aware of the ROME criteria (40%) were primarily using the ROME II or III criteria.8 In our study, many pediatricians are applying their own clinical experience to diagnose childhood FC rather than implementing updated international consensus (ROME criteria) in everyday practice. General pediatricians more commonly chose ≤ 1 defecation per week as a diagnostic criterion for FC than PGs, which suggests that the diagnosis and treatment of pediatric FC may be delayed in a primary-care setting.

The Rome Foundation Working Team reported a deficiency in the knowledge and use of the ROME criteria, especially among general practitioners.9 Borowitz et al.10 reported that American primary-care pediatricians had a lack of familiarity with the ROME criteria. Koppen et al.11 reported that approximately one third of their surveyed respondents were unfamiliar with the ROME criteria, and this unfamiliarity was more common among general pediatricians and physicians from the United States than those from the Netherlands.

The diagnosis of pediatric FC is based on a “positive” approach that avoids unnecessary tests to rule out an organic cause.1213 Scarpato et al.8 reported that 42% of pediatricians considered FC a diagnosis of exclusion that was reached after a thorough diagnostic evaluation for other etiologies. The 2014 European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN/NASPGHAN) joint guideline for FC in children recommends that a patient's history and a physical examination should be used for diagnosis rather than routine tests in the absence of severe symptoms.1 In this study, most respondents answered that they did not perform diagnostic evaluations unless an organic disease was suspected.

The Rome criteria and 2014 ESPGHAN/NASPGHAN guideline recommend DRE when a diagnosis of FC is uncertain,1 because it helps clinicians discriminate FC from other organic diseases and functional non-retentive fecal incontinence.167 However, several studies have shown that DRE is often avoided in clinical practice, with 43%–61% of practitioners either never or only occasionally performing the procedure,8111415 and these results are similar to our findings.

The 2014 ESPGHAN/NASPGHAN guideline states that PEG and rectal enemas are equally effective for fecal disimpaction in FC treatment.1 Bekkali et al.16 reported no difference between the effectiveness of an enema and that of high-dose oral PEG for fecal disimpaction. The working-group guideline prefers PEG for fecal disimpaction, because it is an oral agent.1 A recent study showed that the majority of respondents (67.4%) performed fecal disimpaction,17 and others reported frequencies at 20% and 47%, respectively.1018 In our study, fecal disimpaction was performed by 78.8% of respondents, primarily using rectal enemas (59.1%) and PEG (15.3%). A study in the Netherlands and United States reported that the majority of responders used PEG for fecal disimpaction.11 Widodo et al.19 reported that pediatricians preferred lactulose over rectal enemas for fecal disimpaction. We found that fecal disimpaction was frequently performed before the maintenance treatment, and the specific methods used were based on the clinician's personal choice and regional culture, instead of the international consensus or current guidelines.

The 2014 ESPGHAN/NASPGHAN guideline states that PEG is superior in the effectiveness, adherence, and safety of fecal disimpaction and maintenance treatment for pediatric FC.1 PEG is available in two molecular weights: PEG 3350 and PEG 4000.20 Previous reports showed a significantly frequent stool passage in PEG than in placebo or lactulose.212223 In a previous study, most respondents preferred PEG, with a higher use in children aged > 1 year; however, lactulose was used as frequently as PEG in children aged < 1 year.11 Another study reported that lactulose was used most frequently, and PEG was used in only 10% of respondents.17 Borowitz et al.10 reported that magnesium hydroxide was the most commonly prescribed laxative (77%).

The respondents in our study most commonly chose lactulose, followed by PEG 4000 and probiotics. We found different prescription practices according to age (≥ 1 year and < 1 year) and between PGs and general pediatricians. General pediatricians may lack information about or experience with PEG. General pediatricians tend to use probiotics more than PGs in both age groups. Several other studies have shown the same tendency to frequently prescribe pre-, pro-, or synbiotics for pediatric FC.2425 Theoretically, alterations of gut microbiota can enhance gut motility through the production of short-chain fatty acids that lower the Ph in the colon and result in better colonic peristalsis and a decrease in colon transition time.26 However, no sufficient clinical evidence has been presented to support the use of probiotics, and the 2014 ESPGHAN/NASPGHAN guideline does not recommend their routine usage.1

Koppen et al.27 recommended that maintenance treatment should be continued for at least 2 months, and a weaning initiation should begin after a symptom-free duration of 1 month. Pijpers et al.28 reported that only 50% of pediatric patients with FC had symptom remission and laxative independence after 12 months of treatment, these results correlate with the 2014 ESPGHAN/NASPGHAN guideline that states approximately 50% of pediatric patients with FC referred to pediatric gastroenterologists will recover and stop pharmacologic treatment after 6–12 months.1 Some surveys showed a short duration of treatment for < 1 month, in 45%–86% of respondents.1719

The total treatment duration in our study was significantly longer in the PGs than that in the general pediatricians. PGs are more aware of the importance of adequate treatment duration, and may care for children whose symptoms are more complicated. To our knowledge, this study is the first to explore the differences in treatment duration between PGs and general pediatricians. No randomized-controlled trials have investigated the optimal duration of medical treatment in children with FC.1

The non-pharmacologic treatments were not being actively performed in our study. However, defecation diaries were used more frequently by the PGs than the pediatricians. Education is regarded as the first step in the non-pharmacologic treatment of pediatric FC for both parents and children, but more than half of the respondents in our study do not actively educate. Approximately 60% of the respondents in our study provide detailed explanations on toilet training for constipated children.

The dietary fiber, fluid, and physical activity are recommended with normal intake and level.1 Dietary intervention, such as an increase in fiber or fluid intake, is commonly recommended in pediatric FC.101529 In our study, the participants recommended diet modification primarily with an increase of fluid and fiber intake. Randomized-controlled trials have been performed about the effects of dietary fiber in pediatric FC.303132 A recent Korean study reported an enhancement of bowel movement and better stool consistency in pediatric patients with additional fluid intake during treatment of FC with PEG 4000,33 however, the quality of the evidence was low according to a recent systematic review.34

We found several discrepancies between actual practice and the ROME IV criteria, and between PGs and general pediatricians. Active educational efforts and activities are needed for primary care physicians in the practice of pediatric FC. Our survey data may aid in the construction of practical guidelines in consideration of the regional characteristics in the aspect of social culture, diet characteristic, and the general medical environment, and educational programs for pediatric FC.