Nursing interventions for pediatric functional constipation: a systematic review of evidence and clinical implications

Abstract

Background

Functional constipation (FC) is one of the most common gastrointestinal disorders in children and may substantially affect physical well-being, emotional health, and quality of life. Nurses play an important role in providing behavioral support, education, and implementing supportive interventions; however, evidence regarding the effectiveness of nursing interventions in pediatric FC remains fragmented. This systematic review aimed to synthesize current evidence on nursing-led and nursing-integrated interventions for pediatric functional constipation and evaluate their clinical implications.

Methods

A comprehensive literature search was conducted across PubMed, Scopus, Web of Science, Medline, Embase, and other relevant databases to identify studies evaluating nursing-related interventions in children with FC. Nurse-led educational, behavioral, supportive, and complementary interventions were eligible. Risk of bias was assessed using study design-specific tools.

Results

Eleven studies involving approximately 65,500 children were included. Of these, 64,985 participants were enrolled in cohort, cross-sectional, and observational studies, whereas 530 participants were included in intervention-based studies (randomized controlled trials, clinical trials, and quasi-experimental studies). The evaluated interventions included nurse-led educational programs, structured bowel management strategies, abdominal massage, and technology-assisted approaches such as mobile applications and digital educational games. Overall, nursing-related interventions were associated with improvements in stool frequency, stool consistency, constipation symptoms, treatment adherence, self-management, and quality of life among children and their caregivers.

Conclusions

Nursing-led and nursing interventions appear to be valuable adjuncts in the management of pediatric functional constipation. However, the available evidence remains heterogeneous, and additional high-quality studies are needed to establish standardized approaches and determine long-term effectiveness.

Clinical trial number

Not applicable.

Introduction

Functional constipation (FC) in children is one of the most common health problems worldwide, and has a substantial impact on their quality of life. International evidence indicates that the prevalence of childhood constipation ranges from 3% to 14%, with the highest incidence occurring during the preschool years [1, 2]. FC is typically characterized by a reduced frequency of bowel movements, defined as two or fewer defecations per week [3, 4].

This condition commonly presents with symptoms such as painful defecation, abdominal discomfort, fecal incontinence, bloating, and decreased appetite. These manifestations can significantly affect a child’s physical, psychological, and social well-being, interfering with daily activities, academic performance, and peer relationships. Constipation accounts for approximately 3–5% of general pediatric physician visits and nearly 10–25% of referrals to pediatric gastroenterology specialists [5–7]. Constipation in children tends to occur more frequently during three developmental periods: the transition from breastfeeding to formula feeding or weaning in infancy, the toilet-training stage in toddlers, and the beginning of school or periods when children avoid defecation at school. Among these stages, the peak onset of constipation occurs during toilet training between the ages of 2 and 4 years. More than 40% of children diagnosed with constipation at or before the age of four continue to experience symptoms during school age despite receiving treatment [8]. In addition, childhood constipation is associated with a higher risk of psychological symptoms and subsequent mental health disorders. Although appropriate treatment can improve quality of life, early diagnosis and effective management remain essential [9].

This disorder may lead to pain, fecal incontinence, and significant secondary consequences, including school absenteeism, social withdrawal, and potential onset of depression [10, 11], which ultimately contributes to increased healthcare costs [11]. The etiology of FC is multifactorial, involving an interaction of biological, psychological, and social factors. Among the most important contributors are unhealthy dietary patterns, insufficient intake of fluids and dietary fiber, sedentary lifestyle, negative experiences during toilet training, and psychological stressors [3, 12]. Studies have demonstrated that frequent consumption of fast food, low dietary fiber intake, and sedentary behaviors significantly increase the risk of functional constipation in children [4, 13]. The management of chronic constipation generally includes a combination of pharmacological and non-pharmacological interventions. Pharmacological treatments primarily involve the use of laxatives, including stimulant laxatives, stool softeners, and fiber supplements; however, long-term use of these medications may be associated with adverse effects and dependency [7, 14]. Non-pharmacological approaches focus on dietary and behavioral modifications, including increasing fiber and fluid intake, implementing behavioral interventions, and using complementary methods such as abdominal massage [7, 15].

Overall, FC management commonly prioritizes non-pharmacological strategies, with the most frequently used interventions including lifestyle modifications (such as increased physical activity), dietary interventions (including fiber supplementation, a balanced diet, and adequate fluid intake), behavioral therapies, and education for both children and their families [3, 4].

Despite the high prevalence of functional constipation and its significant impact on patients’ physical and psychosocial well-being, effective prevention and management remain challenging. Nurses play a key role in education, lifestyle modification, behavioral support, and the promotion of healthy bowel habits. Although previous reviews have evaluated non-pharmacological treatments and guideline-based management strategies for pediatric functional constipation, few have specifically focused on the contribution of nursing-led or nursing-integrated interventions. Existing reviews have generally examined broader management approaches without distinguishing the specific roles of nursing education, behavioral support, family-centered care, and complementary nursing therapies. Therefore, this review addresses an important knowledge gap by systematically synthesizing evidence regarding the effectiveness and clinical implications of nursing interventions in pediatric functional constipation.

Materials and methods

This study used the PRISMA 2020 approach for Systematic Review (PRISMA-SR) [16].

Eligibility criteria

We applied predefined inclusion and exclusion criteria to identify relevant studies investigating nursing-related interventions for pediatric functional constipation (FC). The interventions of interest included abdominal massage, exercise programs, acupressure, nutritional strategies, thermal stimulation, and individualized nursing education. Detailed outcome data showed that most interventions resulted in clinically and statistically significant improvements compared with routine care or control conditions. Chronic constipation was defined according to the Rome III /IV diagnostic criteria [4, 7, 17].

Inclusion criteria

(1) Population: All children (< 18 years) in the community, regardless of gender or geographic location, who received nursing interventions for the prevention and treatment of constipation. (2) Intervention: Any nursing intervention aimed at preventing or treating constipation, including massage, nursing education, acupressure, and nutrition education [4, 7, 8, 11, 17–21]. (3) Comparator: No treatment, placebo, or usual nursing care. Studies without explicit comparators (e.g., single-arm or exploratory studies) may be included depending on the review design. (4) Outcomes: Any reported treatment effect related to the prevention or treatment of constipation. (5) Study design: All study types, such as clinical trials, cohort studies, case-control studies, qualitative studies, cross-sectional studies. (6) Language and time frame: Articles published in English after the year 2000.

Exclusion criteria

Population: Patients over 18 years of age, individuals with intestinal obstruction, or patients hospitalized for reasons other than constipation. Additionally, patients admitted to specialized departments such as ICU, CCU, and dialysis were excluded from the study. 2) Intervention: Surgical interventions performed to relieve intestinal obstruction. 3) Comparator: Studies in which the intervention method or measures taken were unclear and unspecified. 4) Outcomes: Studies that did not report any therapeutic effect related to the prevention or treatment of constipation. 5) Study design: Guidelines, protocols, reviews, editorials, expert opinions, short summaries, and conference abstracts without full-text availability. 6) Language and time frame: Articles published in languages other than English (without available official English translation) or published before the year 2000.

Information sources

We extensively searched across electronic databases, including Embase, PubMed, Google Scholar, Scopus, Cochrane Library, and Web of Science [22], until May 2026. Furthermore, we expanded our literature review by checking the reference lists of the studies included in our analysis.

Search strategy

A combination of keywords and medical subject headings (MeSH terms), appropriate to each database, was used to ensure broad coverage. Key search terms included nursing care, nursing intervention, nursing management, constipation, bowel dysfunction, and similar words. The specific search strategies for each database are detailed in Table 1.

Table 1.

Search strategy in different databases

Database	Search strategy
PUBMED	((nurse* OR “nursing care” OR “nursing intervention*” OR “nursing program*” OR “nursing management” OR “nurse managed” OR “nurse delivered” OR “nurse based” OR nurse-led OR “nurse-led care” OR “nurse role” OR “nurse therapy” OR nursing-led OR “nursing intervention”) AND (constipat* OR “bowel dysfunction” OR “bowel disorder*” OR “fecal retention” OR “fecal impaction” OR “defecation disorder*” OR “gastrointestinal motility disorder*” OR “chronic constipation”) NOT (“Systematic Review“[Publication Type] OR “Review“[Publication Type] OR “Meta-Analysis“[Publication Type])
scopuse	TITLE-ABS-KEY (nurse* OR “nursing care” OR “nursing intervention*” OR “nursing program*” OR “nursing management” OR “nurse managed” OR “nurse delivered” OR “nurse based” OR nurse-led OR “nurse-led care” OR “nurse role” OR “nurse therapy” OR nursing-led OR “nursing intervention”) AND TITLE-ABS-KEY (constipat* OR “bowel dysfunction” OR “bowel disorder*” OR “fecal retention” OR “fecal impaction” OR “defecation disorder*” OR “gastrointestinal motility disorder*” OR “chronic constipation”)
Medline	XB (nurse OR “nursing care” OR “nursing intervention” OR “nursing program” OR “nursing management” OR “nurse managed” OR “nurse delivered” OR “nurse based” OR “nurse-led” OR “nurse-led care” OR “nurse role” OR “nurse therapy” OR “nursing-led” OR “nursing intervention”) AND XB (constipat* OR “bowel dysfunction” OR “bowel disorder*” OR “fecal retention” OR “fecal impaction” OR “defecation disorder*” OR “gastrointestinal motility disorder*” OR “chronic constipation”) NOT XB (“systematic review” OR “meta-analysis” OR scoping)
EMBASE	(nurse: ti, ab, kw OR ‘nursing care’:ti, ab, kw OR ‘nursing program’:ti, ab, kw OR ‘nursing management’:ti, ab, kw OR ‘nurse managed’:ti, ab, kw OR ‘nurse delivered’:ti, ab, kw OR ‘nurse based’:ti, ab, kw OR ‘nurse-led’:ti, ab, kw OR ‘nurse-led care’:ti, ab, kw OR ‘nurse role’:ti, ab, kw OR ‘nurse therapy’:ti, ab, kw OR ‘nursing led’:ti, ab, kw OR ‘nursing intervention’:ti, ab, kw) AND (constipat*:ti, ab, kw OR ‘bowel dysfunction’:ti, ab, kw OR ‘bowel disorder*’:ti, ab, kw OR ‘fecal retention’:ti, ab, kw OR ‘fecal impaction’:ti, ab, kw OR ‘defecation disorder*’:ti, ab, kw OR ‘gastrointestinal motility disorder*’:ti, ab, kw OR ‘chronic constipation’:ti, ab, kw) NOT (‘systematic review’:ti, ab, kw OR ‘meta-analysis’:ti, ab, kw OR scoping: ti, ab, kw)
Cochrane Central Register of Controlled Trials	(nurse* OR “nursing care” OR “nursing intervention*” OR “nursing program*” OR “nursing management” OR “nurse managed” OR “nurse delivered” OR “nurse based” OR nurse-led OR “nurse-led care” OR “nurse role” OR “nurse therapy” OR nursing-led OR “nursing intervention”) AND (constipat* OR “bowel dysfunction” OR “bowel disorder*” OR “fecal retention” OR “fecal impaction” OR “defecation disorder*” OR “gastrointestinal motility disorder*” OR “chronic constipation”) NOT (“Systematic Review” OR review OR “Meta-Analysis”) in Title Abstract Keyword - (Word variations have been searched)
Wos	TS=(nurse* OR “nursing care” OR “nursing intervention*” OR “nursing program*” OR “nursing management” OR “nurse managed” OR “nurse delivered” OR “nurse based” OR nurse-led OR “nurse-led care” OR “nurse role” OR “nurse therapy” OR nursing-led OR “nursing intervention”) AND TS=(constipat* OR “bowel dysfunction” OR “bowel disorder*” OR “fecal retention” OR “fecal impaction” OR “defecation disorder*” OR “gastrointestinal motility disorder*” OR “chronic constipation”) NOT TS=(“Systematic Review” OR review OR “Meta-Analysis”)

Selection process

Initially, a researcher imported all search results into EndNote Desktop software to remove duplicates. Afterwards, two researchers independently screened the titles and abstracts of the articles against the eligibility criteria. In case of disagreements regarding study inclusion, the full texts were reviewed, and a third researcher was consulted to reach a consensus. Efforts were made to contact the corresponding authors of the inaccessible articles or those with unpublished data. The PRISMA 2020 flow diagram shows the entire screening process [16] (Fig. 1).

Fig. 1.

Flow chart of screening process

Data extraction

A total of 4,982 articles were identified through keyword searches. After removing duplicates, 2248 articles underwent initial screening based on titles and abstracts, which resulted in the exclusion of ineligible studies. The full texts of 89 articles was retrieved for detailed review. At this stage, 78 other articles were also excluded, and finally 11 articles published from 2011 to 2025 were selected for final inclusion (Fig. 1). A manual search of the reference lists of the included articles did not yield any additional studies meeting the predefined inclusion criteria.

For each eligible study, a standard data extraction form was used to collect relevant information. The extracted data included study characteristics (e.g. author, year of publication, study design), participant demographics, intervention type, study outcomes, and reported adverse events (Table 2).

Table 2.

Risk-of-bias assessments

Study	Tool	Main domains/issues	Overall
Bezgin 2023	RoB2	Low risk across most domains	A
Malekiantaghi 2025	RoB2	Some concerns in allocation concealment	B
Atak 2025	RoB2	Some concerns in blinding	B
Meester-Soonius 2025	NOS	Adequate selection and follow-up	A
Hotta 2025	NOS	Limited confounding adjustment	B
Ismail 2011	NOS	Observational limitations	B
Naenen 2025	CASP	Cross-sectional limitations	B
Tappin 2013	RoB2/ROBINS	Moderate concerns	B
Faramarzian 2017	RoB2	Some concerns	B
Faramarzian 2021	RoB2	Some concerns	B
Leszkowicz 2025	RoB2	Some concerns	A

Study risk of bias assessment

To assess the methodological quality and risk of bias of the included studies, we used validated, design‑specific appraisal tools appropriate for the heterogeneous study designs present in this review. Given that the included studies comprised randomized interventions, quasi‑experimental designs, prospective cohort studies, and cross‑sectional descriptive research, a single assessment tool would not provide a fair evaluation across all study types. Therefore, we applied the following standardized instruments:

Randomized and quasi‑experimental studies

For all randomized controlled trials (RCTs) or quasi‑experimental studies, the Revised Cochrane Risk‑of‑Bias Tool for Randomized Trials (RoB 2) was used to evaluate bias [23]. RoB 2 assesses five domains:

• Bias arising from the randomization process

• Bias due to deviations from intended interventions

• Bias due to missing outcome data

• Bias in measurement of the outcome

• Bias in selection of reported results

Each domain is rated as low risk, some concerns, or high risk, leading to an overall risk assessment per study.

Prospective cohort and observational studies

For prospective cohort and other observational designs, the Newcastle–Ottawa Scale (NOS) was employed to assess risk of bias and methodological quality [24]. This tool evaluates three main domains:

• Selection of study groups

• Comparability of cohorts

• Outcome assessment and follow‑up adequacy

Each study is awarded a maximum of 9 stars, with higher scores indicating better methodological quality and lower risk of bias.

Cross‑sectional and descriptive studies

To evaluate cross‑sectional and descriptive research, we employed the Critical Appraisal Skills Programme (CASP) checklist for cross‑sectional studies, which examines the clarity of research aims, appropriateness of methodology, validity of measurement tools, and completeness of reporting [25].

Each included study was independently appraised by two reviewers, with disagreements resolved by discussion and, when necessary, consultation with a third reviewer. Based on the assessments, studies were categorized into three quality levels:

• Grade A (Low Risk of Bias): The study met most or all criteria of the relevant appraisal tool with minimal concerns.

• Grade B (Moderate Risk of Bias): The study met several criteria but had some methodological limitations or unclear reporting that may introduce bias.

• Grade C (High Risk of Bias): The study did not satisfy key criteria of the relevant tool, indicating significant methodological concerns or high risk of bias.

This multi‑tool approach ensured that each study was evaluated fairly according to its design and provided a transparent and reproducible assessment of evidence quality.

Detailed domain-specific judgments for RoB 2, NOS component scores, and individual CASP checklist items were recorded for each study. A summary of these assessments is provided in Table 2.

Data synthesis

We performed a descriptive and qualitative synthesis of the results from all included studies, which are presented in both narrative and tabular forms. A meta-analysis was not performed because substantial heterogeneity existed across studies in terms of intervention characteristics, study designs, outcome measures, participant characteristics, and follow-up duration. Therefore, pooling quantitative effect estimates was considered methodologically inappropriate, and findings were synthesized narratively.

Results

A total of eleven studies published between 2011 and 2025 were included in this systematic review, representing diverse geographical settings including Belgium, the Netherlands, Japan, the United Kingdom, Turkey, Poland, and Iran. The included studies employed a range of methodological designs, including randomized controlled trials, clinical trials, quasi-experimental studies, prospective cohort studies, and observational research. Collectively, the studies involved more than 65,000 children; however, the majority of participants originated from a large population-based cohort study conducted in Japan (n = 63,697) and a cross-sectional study from Belgium (n = 1,218). In contrast, the intervention-focused studies evaluating nursing-related strategies generally enrolled between 30 and 100 participants. Participants ranged from infancy to adolescence, reflecting the broad clinical spectrum of pediatric functional constipation (FC) (Table 3).

Table 3.

The study characteristics

Authors (year)	Country	Study design	Sample size	Participant characteristics	Aim of the study	Intervention	Control group description	Outcome measures	Adverse events
Laura Naenen [18] (2025)	Belgium	Cross-sectional descriptive study	1218 children	Healthy young children (age 2–8 years)	To assess the association between specific toilet training behaviors and functional constipation in young healthy children	-	-	Children who were not toilet trained for bowel movements during the day had 4.3 times higher odds of developing functional constipation. Findings indicate that timely and regular toilet training is an important preventive factor for reducing functional constipation in children using Bristol Stool Chart	-
Marion A. MeesterSoonius [11] (2025)	Netherlands	Prospective cohort study	70 children (51 enema, 19 nasogastric laxatives)	Children aged 0–18 years with severe constipation requiring disimpaction at a pediatric outpatient clinic	To compare the effectiveness of nasogastric laxatives versus rectal enemas for disimpaction and to assess pain and burden experienced by children and parents	Nasogastric administration of laxatives for disimpaction	Rectal enemas used for disimpaction (treatment choice determined by pediatrician with parents/child)	After eight weeks, 98% (50/51) of enema-treated children and 89% (17/19) of those receiving nasogastric laxatives achieved effective stool consistency (Bristol Stool Scale 3–5), with no significant difference in overall effectiveness (p = 0.177).	Not reported
Masashi Hotta [8] (2025)	Japan	Prospective cohort study	63,697 children	Infants participating in the Japan Environment and Children’s Study [26]	To examine the association between TV/DVD screen exposure time at age 1 and the risk of chronic constipation at age 3	observational exposure: duration of TV/DVD screen time	Comparison across exposure categories (0 h, < 1 h, 1–<2 h, 2–<4 h, ≥ 4 h per day)	TV/DVD screen time is associated with progressively higher odds of constipation, and the association was similar for both sexes (p for interaction = 0.36).	Not reported
Nevine Ismail [19] (2011)	United Kingdom	Prospective observational study	50 children	Children aged 1.5–10 years with chronic constipation ≥ 6 months	To assess the impact of a nurse-led constipation clinic on children’s bowel habits, compliance, and parental understanding	Nurse-led constipation clinic: education on constipation physiology, rationale for laxative treatment, encouragement of good toileting behavior; follow-up across three clinic visits over 3–4 months	-	Bowel movement frequency and stool softness improved markedly, from 22% and 43% at the first visit to 86% for both measures at the third visit (p < 0.001)	-
Meryem Atak [4] (2025)	Turkey	randomized controlled trial	Intervention group (n = 23) and control group (n = 23)	children aged 5–8 years diagnosed with functional constipation (FC)	To evaluate the effects of a computer-based game intervention on stool frequency and type, physical activity level, dietary fiber intake, and fluid consumption	Participants were given a constipation education brochure and played a computer-based game.	Participants were given a constipation education brochure	The computer-based game intervention had a statistically significant effect on the number and type of stools, fiber and fluid intake in children with constipation (p < 0.05)
Malekiantaghi [7] (2025)	Iran	RCT	28 participants in the control group and 33 participants in the intervention group.	children (age 4–10 y) with functional constipation	To evaluate effectiveness of abdominal massage as adjunct treatment for pediatric functional constipation	Swedish abdominal massage + standard therapy	Standard therapy	Both groups showed improvements in stool consistency; however, no statistically significant difference was found between them. The intervention group demonstrated a significantly greater reduction in constipation symptoms (Constipation Assessment Scale scores decreased from 14.70 ± 1.29 to 10.21 ± 1.45, P < 0.001.) and fewer episodes of fecal incontinence (from 3.82 ± 1.33 to 2.70 ± 1.33 days/week, P < 0.001) compared to the control group.
Sabiha Bezgin [17] (2023)	Turkye	randomized controlled	15 children in each group	1- to 6-year-old children diagnosed with functional constipation	To examine the effect of 12 sessions of abdominal massage on symptoms and quality of life of mothers in children with functional constipation.	12 sessions of abdominal massage with pharmacological treatment were received.	Only pharmacological treatment was received	As a result of treatment, the stool consistency of both groups was softened, while the symptoms of constipation in the massage group were reduced.
Zohreh Faramarzian [20] (2021)	Iran	clinical trial	48 individuals in the control group and 47 in the intervention group	children aged 3 to 14 years old who referred to clinic	To evaluate the effects of a nurse-based education program on reducing the symptoms of chronic functional constipation in children	A comprehensive nursing program was implemented.	The usual treatment was used.	Nursing education programs had a desirable effect on the reduction of some symptoms of chronic functional constipation
Zohre Faramarzian [21] (2017)	Iran	Clinical trial	Experimental group (47 individuals) and control group (48 individuals)	children aged 3–14 years referring to Clinic	To investigate the impact of nurse-based approaches on functional chronic constipation in children	A combination of nurse-centered and education programs well as conventional medical treatments were used.	Usual medical treatment.	Improvements were observed in both the groups. The percentage of improvement assessed by chi square test in the intervention group was 70.2%. This percentage increased to 83% about 2 and 3 months after the intervention, while in the control group, the improvements were higher by 14 and 10%, respectively (P value > 0.05)
David Tappin [27] (2013)	United Kingdom	Quasi-experimental	Intervention (Children allocated to nurse-led constipation clinics operating within outreach general paediatric services, N = 45). Control (Children living in other postcode areas who received routine consultant pediatrician-led care, n = 58)	Children aged 0–13 years referred by General Practitioners (GPs) with constipation as the main complaint	To evaluate the effectiveness and service outcomes of a structured nurse-led intervention for childhood constipation compared with routine consultant pediatrician-led care.	Nurse-led assessment with pediatrician medical review, education on bowel function and chronic constipation management, NICE-guided medical treatment (disimpaction and macrogol therapy), behavioral intervention: scheduled toilet sitting with positive reinforcement and defecation facilitation techniques Parent-supported self-management approach Duration: Initial appointment: 60 min, Follow-up appointments: 30 min	Standard consultant pediatrician-led assessment and treatment, usual medical management and follow-up according to routine clinical practice	The nurse-led intervention performed well compared with consultant-led care.
Leszkowicz et al. (2025) [28]	Poland	Randomized single-blind study	100 patients	100 child–caregiver dyads; children aged 4–12 years with FC	To evaluate the effectiveness of using a mobile app to support the treatment of functional constipation in children, comparing it to the standard approach of printed recommendations	Mobile application–supported educational and behavioral intervention, including symptom tracking, bowel movement monitoring, psychological support, reward system, and lifestyle guidance versus printed educational materials	For the control group, the content was thus the same, but the format of conveyed information varied.	Significant improvement in symptom control and quality of life. Mean score improvement: 21.4 vs. 12.3 (p = 0.014). Improvements observed in constipation, abdominal pain, bloating, and bowel-related concerns	events reported

Regarding the methodological quality, three studies were classified as Grade A (low risk of bias), whereas eight studies were classified as Grade B (moderate risk of bias). Most studies demonstrated adequate outcome assessment and acceptable methodological rigor; however, common concerns included limited sample size, insufficient reporting of allocation concealment, lack of blinding, and incomplete reporting of confounding variables.

Overall, the included studies investigated nursing-related interventions and behavioral strategies targeting both the prevention and treatment of childhood constipation. The findings were synthesized into four main categories: (1) nurse-led educational and behavioral interventions, (2) complementary nursing therapies, (3) digital and technology-assisted interventions, and (4) preventive behavioral and lifestyle factors associated with constipation risk.

Nurse-led educational and behavioral interventions

Several studies evaluated structured, nurse-led programs focusing on education, behavioral modification, and family-centered care. A prospective observational study conducted in the United Kingdom demonstrated that participation in a nurse-led constipation clinic significantly improved bowel outcomes, with the proportion of children achieving adequate bowel movement frequency and stool softness increasing from 22% to 43% at baseline to 86% at the final follow-up visit (p < 0.001) [19]. The intervention included education on the physiology of constipation, guidance on laxative use, and the reinforcement of appropriate toileting behaviors across multiple clinic visits.

Similarly, clinical trials conducted in Iran assessed comprehensive nursing education programs combined with standard medical treatment [20, 21]. These interventions incorporated caregiver education, bowel habit training, and symptom monitoring. The results showed meaningful reductions in constipation symptoms and improved clinical outcomes compared with usual care. In one study, improvement rates in the intervention group reached 70.2% immediately after treatment and increased to 83% during follow-up periods, demonstrating sustained benefits over time; although, statistical differences between groups were not always significant [21].

A quasi-experimental study from the United Kingdom further evaluated structured, nurse-led services integrated within pediatric care systems [27]. The intervention included nurse-led assessment, education on bowel function, scheduled toilet sitting, behavioral reinforcement techniques, and parent-supported self-management strategies. Outcomes indicated that nurse-led care performed comparably, and in some aspects favorably than consultant-led routine pediatric care.

Complementary nursing interventions: abdominal massage

Two randomized controlled trials investigated abdominal massage as an adjunctive nursing intervention. In a study conducted in Iran, Swedish abdominal massage combined with standard therapy resulted in significantly greater reductions in constipation symptom severity and fewer episodes of fecal incontinence compared with standard therapy alone (P < 0.001); although, improvements in stool consistency were observed in both groups [7]. Another randomized study from Turkey reported that 12 sessions of abdominal massage alongside pharmacological treatment reduced constipation symptoms more effectively than pharmacological treatment alone and enhanced caregiver-related outcomes [17]. These findings suggest that abdominal massage may serve as a beneficial complementary therapy within nursing care plans.

Digital and technology-assisted educational interventions

Innovative digital approaches were examined in a randomized controlled trial evaluating a computer-based educational game designed to promote healthy bowel behaviors [4]. Children who received both an educational brochure and access to the interactive game demonstrated significant improvements in stool frequency and stool type, as well as increased dietary fiber intake and fluid consumption, compared with controls who received education alone (p < 0.05). These results highlight the potential of technology-supported nursing education to enhance engagement and facilitate behavioral change in pediatric patients. Additionally, Leszkowicz et al. (2025) evaluated a mobile health intervention consisting of interactive educational materials, bowel movement and medication trackers, psychological support components, and a reward-based engagement system. Compared with printed educational recommendations, the intervention group demonstrated significantly greater improvements in symptom control and quality-of-life outcomes. The overall mean symptom improvement score was significantly higher in the intervention group than in the control group (21.4 vs. 12.3; p = 0.014). Significant improvements were also observed in constipation-related symptoms, abdominal pain, bloating, and bowel-related concerns [28].

Preventive behavioral and lifestyle factors

Several observational studies focused on behavioral and environmental factors associated with constipation risk, providing important implications for preventive nursing interventions. A large cross-sectional study involving over 1,200 children found that a lack of daytime bowel toilet training was associated with a 4.3-fold increase in the likelihood of functional constipation, emphasizing the critical role of timely and appropriate toilet-training practices [18]. Additionally, a population-based cohort study from Japan involving more than 63,000 children demonstrated that increased TV/DVD screen exposure at one year of age was associated with progressively higher odds of chronic constipation at age three, suggesting a link between sedentary behaviors and constipation development [8].

Comparative medical management within nursing-supported care

One prospective cohort study compared nasogastric laxative administration with rectal enemas for fecal disimpaction in children with severe constipation [11]. Both approaches achieved high treatment success rates, with effective stool consistency observed in 98% of children receiving enemas and 89% of those treated with nasogastric laxatives, showing no statistically significant difference between the two treatments (p = 0.177). These findings indicate that multiple treatment modalities may be effective when delivered within structured clinical care supported by healthcare professionals.

Safety outcomes

Adverse event reporting was limited across the included studies. Most studies did not explicitly report adverse events; however, among the studies that provided safety information, no serious intervention-related complications were identified.

Discussion

Functional constipation (FC) is one of the most prevalent chronic gastrointestinal disorders in children, leading to significant physical, psychological, and social consequences for both the child and their family. This condition is primarily characterized by infrequent bowel movements, painful defecation, hard stools, and, in more severe cases, fecal incontinence, occurring in the absence of an identifiable structural cause. Diagnosis is often based on the Rome IV criteria, which emphasize that affected children experience chronic symptoms for at least one month [29].

Globally, FC has a considerable prevalence, with reports indicating that approximately 9% to over 12% of children are affected across different age groups. In many cases, the condition follows a cyclical pattern where painful defecation leads to stool withholding, which in turn exacerbates constipation symptoms [30].

This disorder is influenced by complex interactions among physiological, psychological, social, and cultural factors. A systematic review and meta-analysis reported that children with FC experience lower quality of life compared to their healthy peers [31].

While pharmacological treatment, particularly with osmotic laxatives such as polyethylene glycol, remains a cornerstone of clinical guidelines, non-pharmacological approaches have gained increasing prominence. These include behavioral education, lifestyle modifications, and supportive interventions, which involve a substantial role for healthcare teams, especially nurses [32].

One of the key findings of this review is that nurse-led educational and behavioral interventions can significantly improve both functional outcomes and quality of life in affected children. Behavioral interventions include proper toilet training (such as timed toilet sitting), the establishment of regular bowel routines, the encouragement of postprandial toilet use, and the implementation of reward systems to reinforce appropriate behaviors. These strategies collectively promote healthy behavioral responses and reduce stool-withholding patterns, aligning closely with the non-pharmacological management approaches emphasized in specialized reviews [32]. Research has shown that educating both children and their families about bowel function and the importance of treatment adherence can increase compliance and prevent the premature discontinuation of therapy. This is particularly important in contexts where parents are concerned about laxative dependency, as appropriate education can modify expectations, beliefs, and willingness to cooperate [32].

Lifestyle factors, such as inadequate dietary fiber and fluid intake, low physical activity, and delayed toilet training, are clearly associated with disease severity. Published reviews emphasize that lifestyle modification is a cornerstone of non-pharmacological therapy and can significantly improve symptoms, even when pharmacological treatment is also applied [29]. In addition to dietary modifications, proper toilet training that fosters a positive, non-coercive attitude in children is a key preventive measure against stool-withholding behaviors. Emphasizing this approach as a foundational treatment is strongly supported by clinical guidelines and disease-specific literature [29].

Studies by Malekiantaghi et al. (2025) [7] and Sabiha Bezgin (2023) [17] demonstrated that abdominal massage significantly improves constipation outcomes. The therapeutic effectiveness of abdominal massage may be attributed to its potential to enhance gastrointestinal motility and stimulate bowel movements; although, the precise physiological mechanisms in children with chronic functional constipation require further investigation. Previous studies have reported that abdominal massage can improve colonic transit time and alleviate constipation symptoms, supporting our findings [33]. Massage facilitates the activation of the parasympathetic nervous system and reduces abdominal muscle tension, consequently enhancing gastrointestinal activity. It has also been associated with increased vagal nerve activity and gastric motility, resulting in more frequent bowel movements and reduced discomfort in patients [17].

Another important finding is that mobile app and computer-based games may be more effective in enhancing bowel motility compared to traditional educational methods. Supporting this, Erdur and Ayar (2020) reported that behavioral and nutritional education significantly increased weekly defecation frequency. Similarly, Santucci et al. (2020) [34] found that after structured educational interventions, most children achieved at least three bowel movements per week. While structured education via brochures was provided to both groups in that study, the greater improvement observed in the intervention group may be attributed to the digital game component. This highlights the potential of technology-based interventions to promote behavioral change in children.

Comparison with previous systematic reviews

Previous systematic reviews on pediatric functional constipation have primarily focused on non-pharmacological management strategies or guideline-directed treatment approaches, rather than specifically examining nursing interventions. Earlier reviews mainly evaluated dietary interventions, probiotics, behavioral therapy, physiotherapy, and complementary approaches without addressing the distinct role of nursing-led care models [35, 36]. More recent systematic reviews and meta-analyses have similarly emphasized non-pharmacological therapies, psycho-educational interventions, physiotherapeutic strategies, and supportive management approaches in children with functional constipation. This systematic review extends previous literature by exclusively emphasizing the contribution of nursing-led and nursing-integrated interventions, including educational programs, abdominal massage, behavioral support, structured bowel management programs, and technology-assisted approaches [37, 38]. The findings suggest that nurses can contribute substantially to enhancing treatment adherence, facilitating symptom monitoring, fostering caregiver engagement, and driving multidisciplinary pediatric constipation management models.

Limitation

Several limitations should be acknowledged. First, substantial heterogeneity existed among the included studies regarding intervention type, outcome measures, study designs, and follow-up durations, limiting comparability across studies and precluding quantitative meta-analysis. Second, most intervention studies had relatively small sample sizes and moderate methodological quality. Third, publication bias may exist because grey literature sources were not systematically searched. Fourth, language bias may have occurred because only English-language studies were included. Finally, the geographic concentration of studies in selected countries may limit the generalizability of findings to broader pediatric populations.

Conclusion

This systematic review suggests that nursing-led and nursing-integrated interventions may represent valuable components of comprehensive management strategies for pediatric functional constipation. Educational interventions, behavioral support, and complementary therapies appear highly promising in improving bowel outcomes, treatment adherence, and quality of life in children with functional constipation. However, the available evidence remains limited by methodological heterogeneity and moderate study quality. Additional high-quality, multicenter studies are needed to establish standardized intervention protocols and determine long-term effectiveness.

Author contributions

All authors contributed to the study design and conceptualization. P.P.A. and F.D. performed literature searches and wrote the manuscript. B.M.A. and M.D. revised the manuscript. All authors read and approved the final manuscript.

Funding

None.

Data availability

The authors confirm that the data supporting the findings of this study are available within the article [and/or its supplementary materials].

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.