pISSN: 2234-8646 eISSN: 2234-8840
Pediatr Gastroenterol Hepatol Nutr 2014 December 17(4):203-208
PEDIATRIC GASTROENTEROLOGY, HEPATOLOGY & NUTRITION
Diets for Constipation
Sun Hwan Bae
Department of Pediatrics, Konkuk University School of Medicine, Seoul, Korea
Chronic constipation is a very common disease in children. Successful treatment of constipation can be achieved
not only with medication but also with lifestyle changes, including a proper diet. Diets including fruits, fluids, and
probiotics are good for constipation. Some dietary components are helpful for constipation, and some are harmful.
In this study, we present diets related to constipation from the literature, and propose some perspectives regarding
diets related to constipation.
Key Words: Constipation, Diet, Fluid, Child
Received：December 13, 2014, Accepted：December 18, 2014
Corresponding author: Sun Hwan Bae, Department of Pediatrics, Konkuk University Medical Center, Konkuk University School of Medicine,
120-1, Neungdong-ro, Gwangjin-gu, Seoul 143-729, Korea. Tel: +82-2-2030-7554, Fax: +82-2-2030-7748, E-mail: email@example.com
Copyright ⓒ 2014 by The Korean Society of Pediatric Gastroenterology, Hepatology and Nutrition
his is an openaccess article distributed under the terms of the Creative Commons Attribution NonCommercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits
unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
The outcome of a disease treatment generally de-
pends on patient or guardian cooperation, partic-
ularly in pediatric patients. In children with func-
tional constipation, the better the patients eat, the
better their bowel movements. This phenomenon is
observed more frequently in young patients with a
defecation diary. This study focuses on diets asso-
ciated with constipation, such as the 3Fs: fluid
(water, juice, and veberage, etc.), fiber, fruits, pro-
biotics, and milk products. Fruits include bananas,
persimmons, kiwifruit, plum, (prune), etc.
The amount of total fiber ingested per day includes
that from dietary and functional fiber sources.
Dietary fiber is nondigestible carbohydrate and lig-
nin that are intrinsic and intact in plants. Functional
fiber includes isolated, nondigestible carbohydrate
that has beneficial physiological effects in humans.
The recommended daily total fiber consumption for
children >1 year is expressed as “age plus 5-(10) g”
or “0.5 g/kg” [1-3]. Common fiber-rich foods include
cereals (rice, corn), bread, vegetables, fruits, pota-
toes (with peel), and whole grains. The mechanism
of action of fiber on constipation includes: 1) Fiber
increases stool bulk and accelerates colon transit; 2)
fermenting fiber produces short-chain fatty acids
(butyrate, propionate, acetate, etc.), which increase
osmotic load and accelerate colon transit; 3)
short-chain fatty acids change the intraluminal mi-
crobiome (mass) directly or indirectly by decreasing
luminal pH, which accelerates colon transit; and 4)
fiber contains water. All these improve stool con-
204 Vol. 17, No. 4, December 2014
Pediatr Gastroenterol Hepatol Nutr
sistency and amount [4-6].
Classically, fiber is classified into water-soluble
and water-insoluble fiber. Water-insoluble fiber in-
cludes cellulose, hemicellulose, methylcelluose, lig-
nin, and synthetic fibers (calcium polycarbophil).
Water-soluble fiber includes gums (fenugreek gum,
guar gum, tara gum, locust bean gum, or carob gum),
pectin, mucilage, psyllium, and glucomannan.
However, this classification is too theoretical to apply
to actual treatment because every component of fi-
ber exists in nature. A more complex classification
for naturally occurring fiber has been proposed.
According to this classification, 1) short-chain carbo-
hydrates or fiber are oligosaccharides. 2) Long-chain
carbohydrates: ① Soluble, highly fermentable non-
starch polysaccharide fiber includes resistant starch,
pectin, inulin, and guar gum. ② Intermediate solu-
ble and fermentable fiber includes psyllium, ispa-
ghula and oats. ③ Insoluble, slowly fermentable fi-
ber includes wheat bran, lignin (flax), and fruits and
vegetables. ④ Insoluble, non-fermentable fiberin-
cludes cellulose, sterculia, and methylcellulose .
Generally, it is well-known that water-insoluble fi-
ber is helpful for constipation. However, some au-
thors insist that intermediate soluble and ferment-
able fiber is helpful for constipation . The Food
and Drug Administration approved methylcelluose,
psyllium, and polycarbophill for constipation as of
2014. Higher dietary fiber intake (fruits, legumes,
and vegetables) is associated with a lower incidence
of constipation in some studies [8,9]. In terms of
treatment, water-insoluble fiber with wheat bran and
rye bread improves bowel movement frequency and
defecation difficulty significantly [10,11]. However,
the water-soluble fiber (psyllium and glucomannan)
results are conflicting [12-14]. As of 2014, North
American Society for Pediatric Gastroenterology,
Hepatology, and Nutrition (NASPGHAN) and Euro-
pean Society for Paediatric Gastroenterology, Hepa-
tology and Nutrition (ESPGHAN) do not support the
use of fiber supplements in the treatment of func-
tional constipation .
For perspective, it is warranted to verify that for
which children and at what point should fiber treat-
ment for constipation begin? How should the fiber
source be selected? Which constipation subtypes
should be considered?
About 10 L of fluid per day, including about 2 L
from the diet, are loaded into the adult gastro-
intestinal tract, and 8.5 L are absorbed by the small
intestine. Another 1.3-1.4 L is absorbed in the colon,
and 0.1-0.2 L is excreted in stool. About 5 L are load-
ed into the gastrointestinal tract of a small child per
day. The absorptive capacity of the small bowel and
colon can increase within a wide range to meet needs
. However, considering toddler’s diarrhea ,
the absorptive capacity of the small bowel and colon
may not reach maturity at least until 5-6 years of age.
Against common sense that drinking water is help-
ful for constipation, many well-known studies, in-
cluding the 2014 ESPGHAN and ESPGHAN paper,
insist that no evidence supports the use of extra fluid
intake to treat functional constipation . However,
additional fluid during treatment for chronic func-
tional constipation led to better outcomes in terms of
bowel movement frequency and stool consistency in
children who were administered polyethylene glycol
(PEG 4000, Forlax; Beaufour Ipsen Pharma., Paris,
France) (Fig. 1 and 2) . Considering the mecha-
nism of action of osmotic and fiber agents, sufficient
fluid intake is helpful for treating constipation.
Fruit juices contain sorbitol, fructose, and phy-
tochemicals as well as water. Some juices have a fiber
component. Fruits juices are generally helpful for
constipation, particularly in young children, whose
intestinal function has not fully matured. Apple,
prune, and pear juices are usually recommended for
Lubiprostone (type-2 chloride channels) and lina-
clotide (cystic fibrosis transmembrane conductance
regulator) are recently introduced drugs for treat-
ment of adult constipation that act on intestinal epi-
thelial ion channels and increase intestinal luminal
water content [19,20]. We believe that lifestyle
changes are important to treat constipation and pre-
Sun Hwan Bae：Diets for Constipation
Fig. 1. Bowel movement scores for patients on polyethylene
glycol 4000 (PEG 4000, Forlax;
Beaufour Ipsen Pharma., Paris,
France). Scores for the better fluid intake periods were signi-
ficantly better than those for the worse fluid intake periods
(median, 27.78; range, 21.43-30.00 vs. median, 25.13; range,
Fig. 2. Stool consistency scores for patients on polyethylene
glycol 4000 (PEG 4000, Forlax;
Beaufour Ipsen Pharma., Paris,
France). Scores for the better fluid intake periods were signifi-
cantly better than those for the worse fluid intake period
(median, 20.00; range, 11.79-20.00; vs. median, 15.91; range,
vent a relapse. Thus, increasing fluid intake is recom-
mended rather than using luminal fluid-increasing
agents in terms of safety and long-term efficacy.
Probiotics are live microorganisms that confer a
health benefit on the host when administered in ad-
equate amounts. Dysbiosis of intestinal flora, high
frequencies of Clostridium and Enterobacteriaceae spe-
cies, which are rarely isolated in healthy children,
have been reported in children with constipation
. The proposed probiotic mechanism for con-
stipation involves 1) Bifidobacteria and lactobacilli
produce lactic acid, acetic acid, and other acids,
which lower pH in the colon and enhance peristalsis.
2) Probiotics may exert anti-inflammatory effect and
immunomodulation effect, which may improve cer-
tain mechanism of dysmotility. 3) Metabolic func-
tions of the altered microbiota may affect intestinal
luminal content. For example, methane gas can slow
gut transit, and probiotics may improve this effect. 4)
Particular probiotic strains stimulate motility and
peristalsis, which is particularly helpful to treat slow
transit constipation .
Lactobacillus reuteri has a positive effect on bowel
frequency in infants with functional chronic con-
stipation but no improvements in stool consistency
are observed . Bifidobacteria (B. bifidum, B. in-
fantis, and B. longum) and Lactobacillus (L. casei, L.
plantarum, and L. rhamnosus) increase bowel move-
ment frequency, decrease fecal incontinence, and re-
duce abdominal pain in children 4-16 years of age;
however, they have no effect on stool consistency
. In one study, Lactobacillus GG was ineffective as
an adjunct to lactulose for treating constipation in
children . As of 2014, NASPGHAN and ESPGHAN
do not support the use of pre- or probiotics in the
treatment of childhood constipation . Some pro-
biotics are helpful for diarrhea, and some are useful
for constipation. Further studies are warranted for
probiotic specificity for diarrhea or constipation. Is
there strain specificity for constipation or diarrhea
within the same Lactobacillus species?
MILK AND MILK PRODUCTS
Breast-milk-fed infants are less frequently con-
stipated than those who are formula fed. Several
mechanisms were proposed for this. 1) Large amounts
206 Vol. 17, No. 4, December 2014
Pediatr Gastroenterol Hepatol Nutr
of prebiotic oligosaccharides in human milk provide
substrates for gut bacteria and this improves osmotic
balance and stool consistency. 2) The fat composi-
tion of human milk may help create softer stools. 3)
Breast milk contains non-digestible oligosaccharides,
which act like dietary fiber, stimulate the growth of
beneficial bacteria, and promote maturation of the
gastrointestinal tract. 4) Breast milk also has the op-
timal whey protein composition and a low phos-
phorous content. 5) Increased levels of gastric in-
hibitory peptide, neurotensin, and vasoactive in-
testinal peptide are observed in formula-fed infants
compared with those in breast-fed infants . A
food allergy to cow milk protein can also cause
constipation. A crossover dietary trial demonstrated
an association between chronic functional con-
stipation and cow milk consumption . In one
study, type IV allergies developed frequently and
lymphocyte stimulation test values were related to
constipation. Symptoms improved in the majority of
infants after eliminating the cow milk antigen .
Colon peristalsis in infants with constipation is abol-
ished after ingesting cow’s milk but recovers after
stopping cow’s milk. Colonic stenosis due to a cow
milk protein allergy mimicking Hirschsprung’s dis-
ease is well known . As of 2014, NASPGHAN and
ESPGHAN state that evidence is conflicting for al-
lergy testing to diagnose a cow milk allergy in chil-
dren with functional constipation . Investigations
into the immunological or biochemical mechanisms
occurring during chronic functional constipation are
required, including investigations of intolerance
Fruits contain water, sorbitol, fructose, fiber, and
phytochemicals. Fruits thought to be useful for
treating constipation are pear, grape, plump, and ap-
ple with peel, which are rich in fiber. Here, some
fruits available in Korea will be considered, includ-
ing green kiwifruit, prune (plum), banana, and
Green kiwifruit significantly increases defecation
frequency, stool volume, softness of bowel motion,
and ease of defecation in adult clinical studies. The
proposed mechanisms for this are as follow: 1) Green
kiwifruit contains 2-3 g of dietary fiber per 100 gm.
Fiber plays a physicochemical role during consti-
pation. 2) Actinidine, a protease enzyme in green ki-
wifruit, stimulates upper gastrointestinal tract mo-
tility. Possible induction of activity in the colon re-
mains to be clarified. 3) Kissper, a peptide in green
kiwifruit, has been characterized by anion selectivity
and ion channeling. 4) Phytochemicals occurring
naturally in the fruit may have biological sig-
A prune is a dried plum, and these fruits are bene-
ficial for constipation. They contain high levels of fi-
ber (6.1 g/100 g), fructose (fructan), and sorbitol
(14.7 g/100 g). Large amounts of phenolic com-
pounds (184 mg/100 g), mainly as neochlorogenic
and chlorogenic acids, may aid in the laxative effect
. Prune juice contains less sorbitol and fiber than
that of prunes. Japanese apricot (Prunus mume;
Mae-sil) increases defecation frequency and con-
traction of the rat colon .
Persimmons are not usually eaten in western
countries; however, they are one of the most popular
fruits in eastern Asia. Several types of persimmon are
available. However, we will classify them into non-
astringent varieties (sweet persimmon), which have
a lower tannin acid concentration, and astringent va-
rieties (mellowed persimmon and dried persimmon),
which have a higher tannin acid concentration.
Astringency of persimmons depends on the quantity
of soluble tannins in the fruit flesh. As persimmons
mature, soluble tannins become insoluble, which
makes the fruit much less bitter. The total quantity of
tannins decreases as the persimmon increases in size
. However, healthy individuals experience pain-
ful defecation when even ripe persimmons are eaten.
Sun Hwan Bae：Diets for Constipation
Tannin acid reduced small intestinal secretions and
inhibits peristalsis. Thus, any forms of persimmons
should be avoided in children with constipation.
Several types of banana are available worldwide.
However, we will consider only the species of banana
that is normally available in markets. Unripe ba-
nanas contain 100-250 mg tannins/100 g and have
high amylase-resistant starch content. Thus, they
can cause or aggravate pre-existing constipation.
This property has been used in the BRAT (banana,
rice, apple sauce, and toast) diet for diarrhea. As ba-
nanas ripen, the quantities of tannins and amy-
lase-resistant starch decrease, while soluble sugars
accumulate. Ripe bananas contain 3 g fiber/120 g,
mostly in the form of soluble fiber. They also contain
amylase-resistant starch and tannins . We rec-
ommend not feeding banana to a constipated child,
as many other good sources of fiber are available.
Constipation cannot be managed using medi-
cation alone. Better short- and long-term outcomes
are achieved with lifestyle changes, including a prop-
er diet. Pediatricians treating a child with consti-
pation should pay more attention to these changes.
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