Authors: MM Tabbers (corresponding author) ; I de Milliano ; MG Roseboom ; MA Benninga 
Functional constipation is a common and frustrating problem in childhood with an estimated prevalence of 3% in the western world . This chronic condition is characterised by infrequent defecation less than three times per week, more than two episodes of faecal incontinence per week, the passage of large and painful stools which clog the toilet and retentive posturing. Upon physical examination a palpable faecal mass is often found in the abdomen and the rectum [2, 3]. It causes distress to child and family and results in severe emotional disturbance and family discord . The pathophysiology underlying functional constipation is undoubtedly multi-factorial, and not well understood. Withholding behaviour is probably the major cause for the development of constipation and might be caused by the previous production of a large, hard painful stool, anal fissures, a primarily behavioural mechanism or the resistance to go to another toilet then their own .
To date, patients are treated with a combination of education, toilet training and oral laxatives. Disappointingly, only 50% of all children followed for 6 to 12 months are found to recover and were successfully taken off laxatives . Another study showed that despite intensive medical and behavioural therapy, 25% of patients developing constipation before the age of 5 years continued to have severe complaints of constipation beyond puberty . Furthermore, in 50% of the patients using these compounds, adverse side-effects were registered such as: abdominal pain, bloating, flatulence, diarrhoea, nausea and bad taste . No data exist concerning possible long-term adverse effects such as electrolyte disturbances, mucosal damage and habituation.
Probiotics are defined as live micro-organisms which when administered in adequate amounts, 106 -109 colony forming units, confer a health benefit on the host . The use of probiotics has entered mainstream medicine and has proven being an effective therapy in many different gastrointestinal disorders, including functional gastrointestinal disorders [9, 10]. However, large trials investigating the efficacy and safety of probiotics in pediatric patients are lacking [11, 12]. Studies in constipated adults with a Bifidus yoghurt, containing Bifidobacterium breve , Bifidobacterium bifidum and Lactobacillus acidophilus , showed a significant increase in defecation frequency without any side effects [13, 14]. Furthermore, a randomized controlled trial using Bifidobacterium breve in preterm infants showed less gas accumulation in the stomach, less vomiting and improved weight gain without any side effects, suggesting a positive effect on gastrointestinal motility  The exact working mechanism of probiotics are not well understood. There are some hypotheses, however, why probiotics might have therapeutic potential for the treatment of constipation. Firstly, a dysbiosis in the gut flora in constipated patients has been suggested which might improve after the ingestion of probiotics [9, 10]. It remains important however to understand if dysbiosis is a secondary manifestation of constipation, or if it is a factor contributing to constipation. Furthermore, probiotics can lower pH of the colon by producing lactic, acetic and other short chain fatty acids....
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