Complementary therapies cover a wide range of treatments, and there is no universal definition for the term. In general, complementary medicines are viewed as therapies that are unconventional, and include treatments such as herbal medicine, massage therapy, homeopathy and food supplements. Often these treatments are given alongside more conventional treatments.

Complementary medicine has been used to treat the symptoms of chronic functional constipation (CFC) in children. Specifically, the use of manipulation techniques such as (hand) massage and reflexology have been used to treat CFC symptoms. In addition, herbal medicine and traditional remedies with either Indian, Chinese or Persian origins have been reported in a number of studies.

In order to provide up-to-date guidance on the effectiveness of complementary therapies in the treatment of children with CFC, we conducted a review identifying studies that reference the use of complementary therapies. Specifically, we wanted to know what types of complementary therapies have been used to treat children with CFC and how effective were they reported to be in alleviating the symptoms.

A scoping review was conducted to identify evidence on interventions to support the management of childhood CFC. This scoping review identified studies of all designs which mentioned management strategies for childhood CFC. Participants were between 0 and 18 years of age, with or without additional support needs. Major electronic databases were searched (Medline and PreMedline, Cochrane library databases, Epistemonikos, Embase, CINAHL, PsycINFO, AMED, and archived databases (DARE, HTA, NHS EED) using adapted established search filters (from SIGN, CADTH and Cochrane). All studies found relating to complementary therapies interventions were then considered in a focussed systematic review. 

In the focused systematic review, studies were selected for inclusion from those reporting on effectiveness of complementary therapy interventions identified in the scoping review. A hierarchical approach was adopted to study selection and inclusion: 1) we identified, performed data extraction on and quality appraised any systematic reviews and meta-analyses; 2) we updated any high quality systematic reviews (SRs) older than a year; and; 3) we identified RCTs and other primary studies reporting on interventions not addressed in a SR, and included these in the synthesis. Study selection, data extraction and assessment for risk of bias were conducted by two independent researchers, with disagreements resolved through discussion, involving a third reviewer when necessary. Data were extracted from identified SRs, RCTs and other primary research studies, and described using the TIDieR framework [1]. For each different type of intervention identified, we provided a summary of evidence and assessed our level of confidence in the findings using the GRADE criteria [2].

Evidence was mapped to different levels of care provision in which the intervention might be provided. The levels of care provision identified were: treatments readily available over the counter delivered by a carer/parent, treatment delivered as part of primary care services, treatment delivered as part of secondary care specialist services and treatment delivered as part of highly specialist, consultant-led tertiary care services.

From the scoping review, 50 papers were identified as being potentially relevant.  After assessment for inclusion in the focussed systematic review, 18 studies were excluded; 12 studies were ongoing, 3 papers were identified as being linked to other studies, 2 papers were duplicates and 2 papers did not address a relevant intervention. 13 papers met the criteria for inclusion. Of these, there were 3 SRs, 3 RCTs, one non-randomised controlled trial and 6 other primary studies. Two of the SRs were classified as high risk of bias and therefore, in line with our protocol, no further data were extracted from these studies. There was a total of 883 participants (age range 7 months to 19 years) included across the 11 studies.

Evidence for the effectiveness of complementary therapies was divided into two categories: use of manipulation techniques (one SR, 2 RCTs, one non-randomised control trial, 4 other primary studies) and use of herbal and/or traditional medicines (one RCT and 2 other primary studies). Manipulation techniques were delivered across primary, secondary, and consultant-led/specialist services: abdominal massage was delivered in the community by specialist health visitors who trained parents/carers in massage therapy; secondary care interventions focused on spinal manipulation, reflexology, acupuncture and electrical stimulation; and interventions delivered/referred to by consultants/highly specialist services included reflexology, cupping therapy, osteopathic manipulation techniques and vertebral adjustments, all delivered by specialists in the area. Herbal medicine based intervention studies addressed the effectiveness of Chinese (Xebt granuals), Indian (Shunthyadi syrup) and traditional Persian medicine on the symptoms of CFC. These treatments were all administered within secondary care at paediatric clinics/tailored medical centres. 

We assessed our confidence in findings relating to 9 different interventions; we found no moderate or high GRADE evidence; we had low confidence in evidence for 3 interventions and very low confidence for 5 interventions.  Aspects of care where there is some low GRADE evidence for the effectiveness of complementary therapies are: (i) there is very low quality evidence that abdominal massage for children with an identified disability and CFC may result in equivalent or better outcomes than standard care alone, when delivered as part of primary care services; (ii) when delivered as part of secondary care services, there is low quality evidence that herbal/traditional medicine for children with CFC may result in equivalent or improved outcomes when compared to standard care alone; (iii) when delivered as part of secondary care services, there is very low quality evidence that manipulation techniques result in better or comparable outcomes to standard care alone.

Evidence on the use of complementary therapies in the treatment of childhood functional constipation is of low quality. At best, we have low confidence in the evidence that does exist. In addition, there is no reference to the role of complementary therapy use in the NICE guidelines [3].

Recommendations centre around the need for more high-quality studies to investigate the use of complementary therapies as a treatment option for CFC. In addition, provision of greater clarity of selection criteria, accepted definitions of childhood constipation and outcome measures in such studies is called for.

Hoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, Moher D, et al. Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ. 2014;348:g1687.
Atkins D, Best D, Briss PA, Eccles M, Falck-Ytter Y, Flottorp S, et al. Grading quality of evidence and strength of recommendations. BMJ 2004;328:1490.
NICE Guidelines. Constipation in children and young people; diagnosis and management. Published 26 May 2010, Last updated: 13 July 2017. Available: https://www.nice.org.uk/guidance/cg99 [Accessed 4.5.21]