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Dietary treatments for childhood constipation: efficacy of dietary fiber and whole grains

Maria L Stewart , Natalia M Schroeder
DOI: http://dx.doi.org/10.1111/nure.12010 98-109 First published online: 1 February 2013

Abstract

Constipation in children is defined on the basis of several clusters of symptoms, and these symptoms are likely to persist into adulthood. The aim of this review article is to summarize the current literature on the use of dietary fiber and whole grains as treatments for childhood constipation. Current recommendations for fiber intake in children vary substantially among organizations, suggesting that the function of fiber in children is not fully understood. Additionally, no formal definition of “whole grain” exists, which further complicates the interpretation of the literature. Few randomized controlled trials have examined the effect of dietary fiber supplementation in children with constipation. Currently, no randomized controlled trials have investigated the efficacy of whole grains in treating childhood constipation. This is an area that warrants further attention. Increasing the intake of dietary fiber and/or whole grain has the potential to relieve childhood constipation; however, additional randomized controlled trials are necessary to make a formal recommendation.

  • children
  • constipation
  • fiber
  • whole grains

Introduction

Definitions and symptoms of constipation

Constipation may be categorized as “organic” constipation or “functional” constipation, depending on the cause. Organic constipation results from a documented pathological condition such as anatomical malformations, abnormal abdominal musculature, connective tissue disorders, metabolic or gastrointestinal diseases, neuropathic disorders, or intestinal or nerve disorders.1 Functional constipation accounts for the majority of diagnoses and is caused by situational, psychological, developmental, or dietary issues.1 Behavioral factors such as toilet training and negative feelings toward public toilets are also causes of functional constipation.2,3 Constipation may result from a previous painful defecation, with the child avoiding defecation to avoid a repeat painful experience.4 Food allergy is also associated with functional constipation in children, with milk, egg, and wheat being the most common allergens associated with constipation.5 Dietary factors such as fluid and dietary fiber intake are contributors in the development of functional constipation.6

Functional constipation is commonly experienced during childhood after a child has been toilet trained, and often begins in the first year of life.7,8 However, the definition and criteria for diagnosis of constipation can vary widely. Criteria for diagnosing childhood constipation are summarized in Table 1.912

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Table 1

Criteria for diagnosing childhood constipation

The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN), Rome III, and Boston Working Group definitions of constipation in children are in contrast to the more general definition commonly used in adulthood of “fewer than three bowel movements per week.”13 The number of bowel movements per week typically decreases as children age until age 4, which may limit the usefulness of this measure for diagnosing constipation in children under the age of 4 years.1

Many of the recurring symptoms that accompany constipation exacerbate the associated negative consequences. Hard stool is a common symptom that can lead to withholding (of stools), irritability, and fear of a bowel movement. Stool retention results in rectal distension, loss of rectal sensation, and loss of further urge to defecate, resulting in fecal incontinence (formerly termed encopresis or fecal soiling).14 Other complications include abdominal distension, recurrent abdominal cramping, decreased food intake, vomiting, urinary incontinence, urinary tract infections, depression, low self-esteem, and anal prolapse, fissures, or hemorrhoids.1,7,14,15

Prevalence and medical treatment of constipation

The prevalence of constipation in children varies widely, depending on the diagnostic criteria and the data collection methods. A meta-analysis of peer-reviewed publications published from 1971 to 2005 found that constipation was prevalent in 0.7%–29.6% of children.8 The studies evaluated used a variety of definitions for constipation, and 4 of 18 relied on parent-reported data. More recent survey data, collected by the Agency for Healthcare Research and Quality Medical Expenditure Panel Survey, suggest 1.1% of children suffer from constipation, with a higher prevalence in ages 0–9 years than in ages 10–18 years.16 Data obtained from parent reports (National Center for Health Statistics, National Health Interview Survey, and Medical Expenditure Panel Survey) show a lower prevalence of constipation (0.5–0.6% of children surveyed) than data collected from medical records.1719 This may be an artifact in defining constipation. Although standard definitions and diagnostic criteria have been published (Rome III, NASPGHAN), these are not always used in research and clinical practice. Many studies on childhood constipation were planned before the Rome or NASPGHAN criteria were published, which is a limitation when determining the prevalence of childhood constipation. Despite these differences, one can estimate that childhood constipation affects a significant proportion of children, and current prevalence data may underestimate the actual occurrence.

Current treatments for childhood constipation remain somewhat controversial, and common medical and dietary treatments are summarized in Table 2.9,2022 A meta-analysis of 14 prospective follow-up studies reported that 60.6% of children with functional constipation were symptom free after 6–12 months, demonstrating that treatment is successful for most children.23 In a prospective study, Van Ginkel et al.24 found 60% of children to be symptom free after 1 year of follow-up and 80% to be symptom free after 8 years. However, as mentioned in the previous section, in a substantial proportion of children with constipation, symptoms will continue into adulthood. Further work is needed to identify factors that cause chronic childhood constipation to continue into adulthood.

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Table 2

Clinical treatments for childhood constipation

Impact of breastfeeding

Breastfeeding may have protective effects against constipation in infants. Breast-fed infants had increased stool frequency and fewer hard stools versus formula-fed infants (1.1% of exclusively breast-fed infants versus 9.2% of formula-fed infants).25,26 Softer stools associated with breastfeeding may be explained by several different mechanisms. Increased levels of gastric inhibitory polypeptide, motilin, neurotensin, and vasoactive intestinal peptide secretions in formula-fed infants compared with breast-fed infants may explain the slower intestinal transit in formula-fed infants. In addition, greater stimulation of the gastrocolic reflex from frequent breastfeeding increases defecation. Moreover, the large amounts of prebiotic oligosaccharides in human milk provide substrate for gut bacteria, resulting in improved osmotic balance and improved stool consistency. Lastly, the fat composition of human milk may help create softer stools.27 Because breast milk contains nondigestible oligosaccharides, which act as dietary fiber, breast-fed infants are exposed to dietary fiber very early in life. This early exposure to dietary fiber may protect against childhood constipation by stimulating the growth of beneficial bacteria and promoting the maturation of the gastrointestinal tract.

Childhood constipation affects various aspects of life for both children and caregivers. Due to the broad impact that constipation may have, it is prudent to understand current therapies, specifically nutritional therapies that can be incorporated into the habitual diet. As demonstrated by the protective effect of breastfeeding, diet may influence the development and/or treatment of childhood constipation. Dietary components such as dietary fiber are often recommended to improve bowel habits. Whole grains are a common source of dietary fiber in the diet. The following sections will examine current recommendations for dietary fiber and whole-grain intake in children, actual intake of dietary fiber and whole grain in children, and evidence of the use of dietary fiber and whole-grain intake as a treatment for constipation.

Review of Fiber, Whole Grains, and Constipation

Current dietary recommendations for fiber and whole-grain intake in children

The Institute of Medicine defines dietary fiber as the “nondigestible carbohydrates and lignin that are intrinsic and intact in plants.”28 Functional fiber includes isolated, nondigestible carbohydrates that have beneficial physiological effects in humans. The sum of dietary fiber and functional fiber is termed “total fiber.” Table 3 presents recommended total fiber intake for children 1–18 years of age, based on the Dietary Reference Intakes, the recommendations of the American Academy of Pediatrics, and the “age + 5” rule.2830 Fiber intakes (expressed as Adequate Intakes) recommended for children and published as part of the Dietary Reference Intakes are based on the adult recommendation of 14 g fiber per 1,000 kcal.28 Energy intakes for each age group were based on dietary intake data from the Continuing Survey of Food Intakes by Individuals 1994–1996 and 1998.31 A report from 1995 suggested using the rule “age + 5” rule to determine fiber intake.29 The authors stated that an upper limit of “age + 10” grams of fiber per day may be safe to consume, as this would be consistent with other recommendations of 10–12 g dietary fiber per 1,000 kcal. For children aged 1–18 years, the American Academy of Pediatrics recommends 4.5 g/day to 34.5 g/day dietary fiber.30 Excessive fiber intake during childhood has the potential to negatively impact energy and nutrient intake by increasing fecal energy losses, reducing energy intake due to increased satiety, and decreasing bioavailability of minerals. Many sources of fiber are high in phytates and oxalates, which decrease iron bioavailability.32 Currently, no evidence supports one fiber recommendation over another, and, as shown in Table 3, the recommendations vary widely.

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Table 3

Recommended total fiber intake for children 1–18 years of age

Whole grains are a common source of dietary fiber in the US diet. Whole grains are defined by the American Association of Cereal Chemists as follows: “Whole grains shall consist of the intact, ground, cracked or flaked caryopsis, whose principal anatomical components – the starchy endosperm, germ and bran – are present in the same relative proportions as they exist in the intact caryopsis.”33 Many foods contain whole grains in addition to refined grains and thus make a partial contribution towards whole-grain intake. The Dietary Guidelines for Americans encourages the consumption of nutrient-dense foods such as whole grains.34 Current recommendations are to “consume at least half of all grains as whole grains. Increase whole-grain intake by replacing refined grains with whole grains.”34 The recommendations to increase whole-grain intake in children and adults aim to increase dietary fiber, ensure normal gastrointestinal function, and prevent chronic diseases. In general, one slice of whole-wheat bread, one-half cup of cooked whole-grain pasta, rice or oatmeal, five whole-grain crackers, or three cups of popped popcorn is equivalent to an ounce-equivalent serving of whole grain. Table 4 summarizes the recommended whole-grain intake for children ages 2–17 years, based on the Dietary Guidelines for Americans and the US Department of Agriculture's MyPlate food guidance system.34,35

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Table 4

Recommended daily whole-grain intake for children

Current fiber and whole-grain intake during infancy and childhood

During infancy, breast milk provides low-digestible carbohydrates that reach the colon intact, thus acting as dietary fiber.36 As solid foods are introduced, cereals (rice and maize) represent the first sources of dietary fiber in an infant's diet. Fruits and vegetables provide additional dietary fiber, which cumulatively amounts to 3.3 g/day for a 12-month-old infant.37 Currently, the mean intake of dietary fiber during infancy in the United States ranges from 0.5 to 6 g/day (Table 5).3847 Excessive dietary fiber intake may negatively impact infant growth, as documented by Dagnelie and van Staveren.48 Infants (4–18 months of age) consuming a macrobiotic diet (6–19 g/day) had twice the dietary fiber intake compared with the control group (5–8 g/day), and this was correlated with reduced growth during the same time period. McClung et al.49 found that increasing dietary fiber intake in 6- to 12-year-olds (from 0.31 g fiber/kg body weight/day to 0.61 g fiber/kg body weight/day) during a 6-month dietary intervention that included supplemental psyllium, bran, and wheat, corn, and oat fiber did not impair growth. However, it should be noted that the peak fiber intake occurred during the middle of the 6-month intervention, and by the end of the 6-month period, fiber intake returned to baseline. High dietary fiber intake may be more detrimental during infancy and early childhood (6–18 months of age) than in older children (6–12 years of age). In the United States, no dietary fiber recommendation has been set for children less than 1 year of age.28 However, Agostoni et al.36 published recommendations such as “increase dietary fiber intake to 5 g/day during ages 6–12 months.”

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Table 5

Dietary fiber intake in children

Daily fiber intake by children has been assessed using a variety of techniques (Table 5). The ranges of means from data presented in Table 5 are as follows: 0.5–10.2 g/day for ages <2 years (2 studies only), 8.2–10.6 g/day for ages 2–5 years (including a study for ages 1.5–3 years), 11.2–19.7 g/day for ages 6–11 years (including intermediate-age studies and 1 study for ages 4–8 years), 13.6–19.5 g/day for ages 9–13 years, and 10.6–23.8 g/day for age 12–18 years (intermediate-age studies inclusive). Using the Adequate Intake values, children in the United States are consuming less than half of the recommended amount of fiber daily. Based on the “age + 5” recommendation, younger children are closer to meeting the recommended daily fiber intake. Hampl et al.50 reported that 45% of 4- to 6-year-olds (n = 603) met the “age + 5” recommendation and 32% of 7- to 10-year olds (n = 782) met this recommendation. However, because many studies group children into age brackets spanning 3–6 years (resulting in a 3–6 g/day range in fiber recommendation), it is difficult to identify which children are indeed meeting their fiber recommendation. Common fiber-rich food sources consumed by children include vegetables, fruits, breads/cereals, and potatoes.38,39,47,50 Additionally, children with higher fiber intakes tend to have an overall healthier diet, with lower fat and cholesterol, than children with a lower fiber intake.50

The whole-grain intake of children in the United States ranges from 0.48 to 1.0 ounce equivalents, with intake tending to increase with age (Table 6).46,5155 Evaluation of whole-grain intake in international reports typically provides intake data in grams of whole grain rather than ounce equivalents. Currently, a universal definition for a whole-grain ingredient and/or whole-grain food does not exist. Developing a common definition would provide greater clarity in reported (either observational or experimental) levels of whole-grain consumption. Whole-grain consumption during adolescence was tracked for 4 years, with no change in intake for boys or girls.53 Of all sources of whole grains consumed, ready-to-eat cereals make up more than 40%, with yeast breads supplying an additional 35%, popcorn 12%, and crackers 6%, based on the National Health and Nutrition Examination Survey 2001–2002 data.56 Breakfast cereals are a major source of whole grain for children, while corn chips and other chips are a major source for adolescents.51

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Table 6

Whole-grain intake in children

Current research on impact of fiber on constipation in children

The medical community is undecided whether diet can prevent or alleviate functional constipation in children. Medical chart review of patients less than 24 months of age showed that 25% of children treated for functional constipation responded to dietary changes (increasing fruit, fruit juices, vegetables, corn syrup).4 In two recent review articles, current data did not support increased fluid and/or dietary fiber intake.20,57 NASPGHAN reported in 2006 that current research was too weak to make recommendations for increasing fiber intake.9 However, short reviews by Rahman et al.21 and Galal et al.58 found increasing dietary fiber to be unharmful and possibly helpful. The following discussion provides an update on the use of dietary fiber to prevent and/or treat childhood constipation.

Three case-control studies demonstrated that higher dietary fiber intakes are associated with a lower incidence of constipation (Table 7).5971 In children ages 3–5 years, constipated children consumed 3.4 g dietary fiber/day, while nonconstipated children consumed 3.8 g dietary fiber/day (P = 0.044).67 These differences in dietary fiber intake were attributed primarily to decreased fruit consumption in constipated children (P = 0.047). Morais et al.61 attributed decreased dietary fiber intake in constipated children (mean age, 6.8 years; 8.7 g versus 12.6 g dietary fiber/day) to lower consumption of legumes and vegetables. Children who did not meet the recommended fiber intake for their age (age + 5 g/day) were more likely to be constipated (odds ratio = 4.1) than children who met the fiber recommendation.

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Table 7

Effect of fiber and/or whole grains on constipation in children

Similar trends were seen in a study of Greek children ages 2–14 years, with the likelihood of constipation increasing significantly as dietary fiber intake dropped.62 Children in the lowest quintile of dietary fiber intake had a relative risk of 8.0 (diet history) and 3.9 (3-day diet record), depending on the nutrient database used for fiber calculation. Additionally, stool consistency softened as dietary fiber intake increased.

Two studies reported that higher dietary fiber intake did not prevent constipation. Of 84 preadolescent children (ages 7–10 years), dietary fiber intake did not differ between healthy and constipated children; however, bowel frequency was significantly lower in children who consumed <75% of the recommended fiber amount (based on age + 5 or g/kg body weight).69 The absolute amount of fiber and fluids consumed by each group did not differ.68 Issenman et al.60 reported that dietary fiber was not correlated with constipation frequency in a prospective study evaluating children at 22 months and 40 months of age. Observational studies indicate that dietary fiber has the potential to prevent constipation, but results have been conflicting and thus further research is needed to confirm this effect.

As alluded to with the observational studies, broad dietary changes may be an effective means to increase dietary fiber intake for the purpose of relieving constipation (Table 7).63,65,71 Chronically constipated children experienced a significant decrease in clinical symptoms of constipation when dietary fiber intake was increased from 46.8% of recommended intake (age + 5 g/day) to 56.3% of recommended intake over a 90-day treatment period.63 Children increased fiber intake by increasing consumption of greens, fruits, fruit juice, and legumes. A diet rich in cereal, bran, grains, vegetables, and fruits effectively decreased the severity of constipation symptoms over the course of 12 weeks in children ages 3–14 years.65 For younger children (mean age 5.77 years), 9.61 g/day was the minimum effective dose of dietary fiber, while for older children (mean age 10.17 years), 13.78 g/day was the minimum effective dose of dietary fiber. Increasing dietary fiber intake through broad diet changes provides added nutritional benefits such as increased vitamin and mineral intake, in addition to increasing dietary fiber intake. The studies presented here demonstrate that a variety of fiber-rich foods (fruits, vegetables, legumes, and bran) may treat constipation in children. However, it is unclear whether dietary fiber alone is responsible for this effect.

Dietary fiber supplements are a common recommendation to relieve adulthood constipation, but limited data exists on efficacy of dietary fiber supplements in relieving childhood constipation. Konjac glucomannan (100 mg/kg body weight), a viscous, fermentable fiber, significantly increased the number of bowel movements per week compared with baseline but not compared with placebo (maltodextrin) in a double-blind, randomized, crossover 4-week trial with constipated children (mean age 7 years).64 Successful treatment, which was physician defined as three or more bowel movements per week, one or fewer soiling episodes per week, and no abdominal pain, was diagnosed in 45% of children consuming konjac glucomannan versus 13% of children consuming placebo (P < 0.05). Parent-defined improvement was reported in 68% of children consuming konjac glucomannan versus 13% of children consuming placebo (P < 0.05). A blend of trans-galactooligosaccharides, inulin, soy fiber, and resistant starch (type 3) was compared with lactulose in an 8-week, double-blind, parallel clinical trial with 42 and 55 children in each group, respectively.66 Both treatments resulted in softer stools (Bristol Stool Chart) and increased defecation frequency. The dose of fiber blend was based on body weight and ranged from 10 g to 30 g of dietary fiber per day from the supplement alone. This dose was sufficient to meet the “age + 5” to “age + 10” recommendation; however, fiber intake from the habitual diet was not considered. The children in this study likely exceeded the recommended fiber intakes when habitual diet is considered, but these data were not reported. A 4-week randomized, parallel clinical trial compared efficacy of partially hydrolyzed guar gum (3–5 g/day, depending on age) with lactulose (1 mL/kg/day) in constipated children.70 Partially hydrolyzed guar gum was as effective as lactulose in improving constipation symptoms (increased bowel movements per week, softer stool consistency, decreased incidence of abdominal pain, stool withholding, and rectal bleeding) in children.

Fiber supplementation in children has been effective in three clinical trials, but in all three trials the fiber selections differed.64,66,70 Further research is necessary to demonstrate reproducibility with a particular type of fiber. Additionally, two of the trials were of a parallel design, which lacks the strength of a crossover design. The studies by Loening-Baucke et al.64 and Kokke et al.66 showed improved gastrointestinal symptoms in children, but both had a high dropout rate (21–35%). Loening-Baucke et al.64 attributed most of the dropouts to lack of follow-up (4-week visit was missed), and Kokke et al.66 attributed the dropouts to refusal to drink the yogurt. It is unknown whether acceptability of the treatment impacted the dropout rate.

Clinical trials in children have several limitations with respect to diet assessment. Because many young children lack reading and writing skills, the data must be collected by a parent or caregiver. Diet assessment techniques vary across the literature, and reported intakes (nutrient and energy) were higher when the diet history was employed compared with the 3-day food records.62 Additionally, children may not adequately assess dietary intake, especially if they are consuming foods and beverages away from home. The ages of children studied in the current literature mostly range from 2 to 17 years. Dietary requirements and intakes vary greatly over this age range, and thus combining data or comparing data across studies may be difficult. For example, Jennings et al.68,69 reported that absolute fiber intake did not differ between constipated and nonconstipated children ages 7–10 years, but when assessed as percentage of recommended intake, fiber intake became a significant variable.

Thus far, the literature is inconclusive on the use of dietary fiber for prevention of constipation. Observational studies show both a positive effect and no effect. It appears that increasing the intake of dietary fiber to recommended levels will not cause harm to a child and may play a role in preventing constipation. Six clinical trials support increasing dietary fiber intake from both foods and supplements to treat childhood constipation. It is possible to exceed recommended fiber intakes using supplements or bran, which may cause more harm than benefit. The greatest limitations in the body of knowledge are the high dropout rates and lack of reproducibility in supplement trials. Future work should be focused on randomized, controlled trials to demonstrate reproducibility of results and to compare dietary changes versus supplements as a means to increase fiber intake and relieve constipation in children.

Until the effects of dietary fiber in very young children are better understood, appropriate strategies to increase dietary fiber include introducing a variety of fiber-rich foods such as fruits, vegetables, and easily digested cereals as solid foods. Increasing the intake of fiber-rich foods by replacing fruit juices with real fruit or switching to juices high in sorbitol, such as prune juice, can help treat constipation. Additionally, foods contributing to constipation should be reduced in the diet. These foods include meat, bread, fried greasy foods, sugary foods (i.e., cookies), and dairy products. Until further evidence is available to compare foods versus supplements, either could be used for treatment of childhood constipation. When recommending dietary fiber as a preventative or therapeutic measure for childhood constipation, healthcare professionals and caregivers should monitor gastrointestinal side effects and growth as indicators of a failure to thrive. If viscous supplements are recommended (guar gum, psyllium, etc.), the supplement should be consumed with copious fluids to minimize the risk of airway and gastrointestinal tract obstruction. Metamucil® (psyllium) or Citrucel® (methylcellulose) can be mixed in 8 ounces of water or juice and taken 1–3 times per day. Appropriate doses are as follows: children 2–5 years, 3/4 teaspoon; 6–11 years, 1/2 tablespoon; and =12 years, 1 tablespoon. After relief of constipation, it is critical to continue a fiber-rich diet with plenty of fluids and to maintain physical activity and a regular toileting schedule.

Current research on impact of dietary whole grains on constipation in children

Limited data address the specific role of whole-grain intake in childhood constipation. Whole grains contain dietary fiber as well as additional phytochemicals, often termed “copassengers,” that have a positive impact on digestive health. Wheat bran, a component of whole grains, improved bowel habits in constipated children over 24 months of age (median dose at follow-up, 3.0–20.0 g/day).71 This dose of bran, coupled with a recommended balanced diet based on the US Food Guide Pyramid, resulted in 60.7% of the children exceeding a daily fiber intake of “age + 10.” In adults, rye bread significantly relieved mild constipation and improved colonic metabolism compared with white wheat bread and common laxatives; however, this has yet to be demonstrated in children.72 In children less than 2 years of age, bran supplementation may not be beneficial. After 1 month of bran supplementation (15 g/day for children 6–12 months, 30 g/day for children 12–16 months), bowel habits normalized, but other biochemical parameters changed, e.g., blood calcium and trace minerals decreased, and counts of proteolytic bacteria increased.59 Increased fecal nitrogen and bile acids were reported in response to bran supplementation, suggesting malabsorption of intestinal contents. Whole grains have the potential to improve bowel habits in children, but more research is needed to confirm this effect. Previous research on whole grains suggests whole-grain foods are better accepted and are consumed in greater amounts when gradually introduced with familiar foods, which should be considered when planning studies in this area.73

Conclusion

Definitions and recommendations appear to play a critical role when determining the impact of dietary treatments such as intake of dietary fiber and whole grains on childhood constipation. With the prevalence of childhood constipation ranging from 0.7% to 29.6%, the true impact of childhood constipation is not well understood. Methods of data collection (parent-reported versus evaluation of medical records) may be an underlying cause for this large range in prevalence. Dietary fiber recommendations for children span a wide range of grams per day, which suggests more work should be done to better understand the role of dietary fiber in childhood health. Additionally, the lack of a definition of whole grain further complicates the assessment of the beneficial effects of whole-grain consumption in preventing or relieving constipation. Other potentially protective components in whole grain, in addition to dietary fiber, are lost in the refining process. These components, often termed “copassengers,” may have a synergistic effect in relieving the symptoms of constipation. Currently, almost no research examines the specific role of whole grains in childhood constipation, thus providing a decided opportunity for future research of whole grains. Determining the definition of whole grain and the recommended intake for relief of constipation may be accomplished in parallel in a well-designed study. As the body of knowledge grows, age stratification will allow for a better understanding of how dietary fiber and whole grains can relieve childhood constipation.

Amidst unclear definitions of constipation and limited evidence for fiber recommendations, many have shown that increasing fiber intake can relieve constipation, and children who consume more fiber on a daily basis are less likely to be constipated than those who consume less fiber. This provides the foundation for more-detailed clinical trials. Neither the appropriate dose of fiber or whole grain nor the food form has been determined. Thus, a focus on the dose and type of fiber as well as the effects of fiber on childhood constipation is warranted. Additionally, children's acceptance of these fiber-rich foods and the likelihood of application (i.e., ease for parents providing the fiber to children or children voluntarily incorporating fiber into the diet) should be scrutinized.

Reducing the prevalence of childhood constipation and improving the efficacy of treatment will have broad impacts, from reducing medical care expenses, to improving the quality of life for the entire family, to improving health status once a child reaches adulthood. Well-designed, controlled, clinical trials are needed to clearly demonstrate the benefit of increased intake of fiber and whole grain in treating and preventing childhood constipation.

Acknowledgments

This article is based on a white paper prepared for Grains for Health Foundation, St. Louis Park, Minnesota, and for which an honorarium was received. The authors are solely responsible for the article's content and conclusions.

Declaration of interest

The authors have no relevant interests to declare.

Footnotes

  • Affiliations: ML Stewart is with the Department of Human Nutrition, Food, and Animal Science, University of Hawaii at Manoa, Honolulu, Hawaii, USA. NM Schroeder is with the Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA.

References

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