Functional constipation (FC) is a pervasive problem in pediatrics. Although pharmaceuticals are commonly used for FC, parents and patients show reluctance or find dissatisfaction with available medications at times. Further, patients often have interest in utilizing nutraceutical supplements and botanicals that are available over the counter. This literature review aims to summarize research studies performed on non-pharmacologic approaches to constipation and to evaluate the safety and efficacy of these modalities. Overall data on non-pharmacologic treatments for childhood constipation were sparse, and though some studies were available for adult populations, pediatrics studies were generally limited, lacking or flawed. Certain supplements, such as prebiotics, probiotics and fiber, are safe and are without significant side effects. Though fiber supplements such as glucomannan, green banana mass, cocao husk and various fiber blends have emerging evidence in children, evidence for psyllium, cellulose and flaxseed only have supportive studies in adults. Other than senna, studies of botanicals indicate significant safety concerns (in particular with Aloe vera with aloin and Cascara sagrada) and insufficient evidence. For patients with a significant behavioral or anxiety component to their FC and exhibit dyssynergia, mind-body interventions (e.g. diaphragmatic breathing, biofeedback, cognitive behavioral therapy, and behavioral modifications) are certainly safe and effective. Finally, movement and manipulative interventions such as abdominal massage, reflexology, acupuncture and transcutaneous nerve stimulation show promise in the field of pediatric constipation, and data is accumulating for efficacy. These modalities require further study to determine mechanisms of action and which populations may benefit the most from these therapies.

Summary: Background: The lower gastrointestinal (GI) tract, formed from the midgut and hindgut, encompasses the colon, rectum and anal canal.Aim: The aim of this review is to provide an overview of the anatomy and physiology of the lower GI tract.Methods: Literature review on anatomy and physiology of the lower GI tract, including normal motility and phases of defecation. It derives its blood supply from the superior and inferior mesenteric arteries while it is innervated by the extrinsic autonomic (the thoracolumbar and sacral nerves) and the intrinsic enteric nervous system. The colon has four layers: mucosa, submucosa, muscularis externa and serosa. The anal canal ends in the internal and external anal sphincters (EASs) involved in continence and defecation. The lower GI tract is predominantly involved in digestion, absorption, defecation and protection. Defecation is a complex process that requires inter‐neural (enteric and autonomic nervous systems), neurohormonal and neuromuscular coordination. It has four phases which include basal, pre‐expulsive, expulsive and end phase. High‐propagating contractions in the colon propel stool to the rectum leading to rectal distention and the recruitment of the recto‐anal inhibitory reflex. Once able, the EAS, under full conscious control, is then relaxed allowing stool to be evacuated. Other defecation reflexes include the gastrocolic, gastroileal and coloanal reflexes.Conclusions: Recent advances provide novel techniques to investigate motility patterns including high‐resolution manometry protocols with automated assessments, magnetic resonance imaging techniques for defecography, wireless motility capsules and fecobionics.

The gastrointestinal (GI) manifestations in children with hypermobile Ehlers–Danlos syndrome/joint hypermobility syndrome (hEDS/JHS) are not well described. We investigated the prevalence of GI disorders in children and young adults with hEDS/JHS through a single‐center retrospective review. Demographic data, clinical history, symptoms, and diagnostic studies were reviewed. Of 435 patients with hEDS/JHS, 66% were females (age 5−28 years). We noted a high prevalence of constipation (61%), dysphagia (32%), dyspepsia and/or gastroparesis (25%), eosinophilic esophagitis (EoE) (21%), and celiac disease (4%) in our cohort. Upper endoscopy and gastric emptying scans had the highest yield to detect abnormalities. Motility studies were abnormal in 31% of the 80 patients who underwent them. Dysphagia symptoms are significantly associated with EoE. Thirty‐three percent of dysphagia patients had EoE, versus 16% of non‐dysphagia patients (p < 0.001). Screening hEDS/JHS patients for GI issues should be routine, with further investigations and referrals guided by identified symptoms.