The psychosocial implication of childhood constipation on the children and family: A scoping review protocol.

Background Constipation is a common problem in childhood that can have psychological, emotional, social, and health-related quality-of-life (HRQOL) consequences on children and their families. Primary or functional constipation (FC) has no known underlying pathology but is associated with lifestyle, psychological, and behavioural factors. Misdiagnosis and inadequate management of constipation can result in chronicity that can continue to adulthood, reducing quality of life for the child and their parents/family. It also causes emotional, psychological and emotional distress and concern for children and their families. This scoping review aims to answer the research question, “What has been reported about the psychosocial implication of childhood constipation among children and their families?” Methods The methodology for this scoping review will draw on the six stages of Arksey and O’Malley Framework and the updated and refined version by Peters et al. (2022). The process and reporting will follow the PRISMA-ScR guidelines. The Population, Concept and Context (PCC) framework will guide the development of inclusion criteria and the search strategy for this scoping review. Systematic literature searches of PUBMED, CINAHL, ASSIA, PsycInfo and Cochrane Library will be conducted from inception to present. The critical appraisal will be performed on selected articles to promote trustworthiness and methodological rigour. Plans for consultation exercise and dissemination of findings will also be presented. Conclusion This scoping review aims to present a comprehensive synthesis of the characteristics and extent of available literature to develop an understanding of and identify gaps in current knowledge regarding the psychosocial implication of childhood constipation on children and their families.


Introduction
Constipation is a defecation disorder that is an increasingly significant and prevalent chronic health problem in children (Walter et al., 2019).Despite this, it is often poorly recognised and inadequately managed (Borowitz et al., 2005;Widodo et al., 2018).Barnes et al.'s (2018) survey on paediatric gastroenterologists and general paediatricians reported a lack of awareness of ROME IV criteria for diagnosis of FC in children.For diagnosis purposes, constipation is categorised as primary or secondary based on its pathophysiology.Primary constipation, also known as functional constipation (FC), has no underlying organic causes and occurs in 95% of children diagnosed with constipation (Koppen et al., 2016;Tabbers et al., 2014).In contrast, secondary constipation has organic pathology such as Hirschsprung's disease, anorectal malformations, hypothyroidism, diabetes mellitus, hypercalcaemia and hypokalaemia (Rajindrajith & Devanarayana, 2011).Diagnosis of functional constipation in children should be guided by the internationally recognised guideline ROME IV criteria, which includes two or more of the following symptoms occurring at least once per week for a minimum period of 1 month: two or less defecations per week, at least one episode of faecal incontinence per week, a history of excessive volitional stool retention or posturing, history of painful or hard bowel movements, presence of large faecal mass in the rectum and a history of large diameter stools that can obstruct the toilet (Hyams et al., 2016).The diagnosis of primary or FC must exclude secondary constipation, as 'red flag' symptoms may point to a more serious underlying disorder requiring further investigations (NICE, 2018).Misdiagnosis and ineffective management of constipation in children can result in chronicity that can last up to ten years (Michaud et al., 2009) and even into adulthood (Bongers et al., 2010;Rajindrajith et al., 2013).
Global epidemiological data on childhood constipation to date is limited.The available data on the prevalence of childhood constipation demonstrates a considerable variation between geographical regions ranging from 0.7% to 32% (Chogle et al., 2016;Játiva-Mariño et al., 2019;Oswari et al., 2018;Udoh et al., 2017;van Tilburg et al., 2015;Wu et al., 2011).The global pooled prevalence is reported at 9.5% and a much higher prevalence of 17.5% in children below four years of age (Koppen et al., 2018).In paediatric gastroenterology clinics, the reported prevalence ranges from 25% to 45% (Benninga et al., 2004;Di Lorenzo, 2000;Loening-Baucke, 2007).This variation may be attributed to a heterogeneity in definitions of constipation, duration of symptoms, methodology of studies, age distribution of children and epidemiological data (Rajindrajith & Devanarayana, 2011).Data on prevalence by age distribution is also limited due to variation in study age groups.Koppen et al.'s (2018) systematic review and meta-analysis found no association between prevalence of constipation in children and age.However, Rajindrajith et al.'s (2012) survey on children and adolescents aged between 10 to 16 years found a negative correlation between prevalence of constipation and age; demonstrating the highest prevalence (24%) in children aged 10 years.In addition, Walter et al.'s (2019) cross-sectional study on children aged between 6.5 and 48 months demonstrated that the highest prevalence (13%) were in children aged between 37 and 48 months.To date, there have been no epidemiological studies to identify the prevalence of childhood constipation in Ireland.
While there is no known underlying cause, there are multiple factors that can lead to the development of constipation in children.Some environmental factors have been linked to a higher risk of this disorder in children for example: a sedentary lifestyle and poor diet, low socioeconomic background, poor maternal education, and cramped living accommodations (Edan & Yahya, 2022;Kilincaslan et al., 2014;Ludvigsson et al., 2006) as well as low levels of interaction with parents (Yamada et al., 2019).Early childhood developmental factors Amendments from Version 1 1. "Can be caused by" was amended to "is associated with" in the abstract.
2. Paragraph 3 was moved to paragraph 2 to inform readers of the prevalence.
3. Epidemiological research describing early childhood psychosocial risk factors for constipation by Joinson et al. (2019) was added.
4. The impact of constipation on the psychological and social wellbeing, and overall HRQOL of children and adolescents in Appak et al. (2017) was discussed in paragraph 5.
5. The limitations were discussed in majority of the studies such as study design, sample size, risk of bias and adjustment for confounders.
6.The cost implications of constipation for families and the burden on healthcare services was expanded to include the importance of early identification and intervention for paediatric constipation.
7. The 'psychosocial' concept was described in more detail in "Eligibility Criteria".8.The review question was amended to "What are the psychosocial impacts of childhood constipation on children and their families?"9. Charities including Children's Health Ireland Family Forum, Youth Advisory Council, Prevention and Early Intervention Network, Children's Rights Alliance and Irish Youth Foundation were added to stakeholders list.10.A discussion of the link between constipation and bladder symptoms such as urinary tract infections, urinary incontinence during the daytime and lower urinary tract dysfunction was added.
11. Details of ROME IV criteria were added and discussed in detail to inform readers.12. Inadequately "treated" was amended to "managed" and the lack of awareness of ROME IV criteria among paediatric gastroenterologists and general paediatricians was discussed.
13.The pooled prevalence reported by a systematic review and meta-analysis was added and described.
14.A discussion on the correlation between chronic constipation and overweight and obesity was added.
15.The association between stressful events and childhood constipation reported by 2 systematic reviews were added and discussed.
Any further responses from the reviewers can be found at the end of the article have also been associated with constipation in young children, such as incidents of painful defecation at a young age leading to withholding behaviour (Kilincaslan et al., 2014;Mugie et al., 2011); authoritarian parenting styles in younger age group (Kilincaslan et al., 2014;van Dijk et al., 2015); stressful childhood incidents such as psychological trauma; physical, verbal and sexual abuse; being bullied in school and inadequate or punishment during toilet training (Edan & Yahya, 2022;Inan et al., 2007;Philips et al., 2015;Rajindrajith et al., 2016;Rajindrajith et al., 2021;Thomaz de Almeida et al., 2021;Walter et al., 2019) as well as alcoholism and severe illness within the family (Oswari et al., 2018). Joinson et al.'s (2019) prospective study reported a significant association between psychosocial problems and constipation.This large study involving 8435 children aged between 4 and 10 years found that psychosocial issues at a young age such as behavioural and emotional problems, temper tantrums and sleep problems were linked to higher levels of constipation and soiling.In addition, stressful incidents at ages between 2 ½ and 4 years were associated with higher levels of constipation and soiling.While the limitation reported in this study was the use of parental report of constipation and soiling, the use of latent classes extracted from a large cohort increases generalisability of findings.Confounders in this study such as sex, sociodemographic measures and child's developmental level were adjusted to increase validity of findings.
Childhood constipation has significant adverse consequences affecting multiple aspects of the life of children.Several studies have reported reduced average weight and height in children with chronic constipation when compared to children without the disorder (Chang et al., 2013;Pawłowska et al., 2018;Yousefi et al., 2019).However, this report is controversial, as other studies have reported on the correlation between chronic constipation and overweight and obesity (Koppen et al., 2016;Olaru et al., 2016;Santos-Andreoli et al., 2019).A recent systematic review and meta-analysis which evaluated eighteen studies involving 33,410 children reported that childhood constipation is associated with the prevalence of overweight and obesity (Lazarus et al., 2022).Children with constipation also demonstrated higher somatic scores when compared to healthy children (Appak et al., 2017;Kilincaslan et al., 2014;Rajindrajith et al., 2013). Rajindrajith et al.'s (2013) cross-sectional survey using Pediatric Quality of Life Inventory and Child Somatization Index on 1792 children aged 13 to 18 reported higher somatisation scores with symptoms including headache, dizziness, lethargy, nausea and vomiting, as well as pain in the abdomen, lower back, chest and limbs/joints when compared to healthy children.These symptoms were found to have a significant effect on the children's health-related quality of life (HRQOL).The large sample size and use of previously validated tools increases the validity and generalisability of this study.The reported limitation to this study was the diagnostic methodology which did not include a physical examination.Also, a generic HRQOL questionnaire was employed which may lack sensitivity and accuracy.Another common problem associated with chronic constipation in children is bladder symptoms including urinary tract infections (Halder et al., 2021;Hoque et al., 2010;Sarvari et al., 2017), urinary incontinence during the day time (van Engelenburg-van Lonkhuyzen et al., 2017) and lower urinary tract dysfunction which includes symptoms such as increased or decrased urinary frequency and bladder overactivity (Burgers et al., 2013;Queiroz Machado et al., 2015;Muhammad et al., 2015;Sampaio et al., 2016) High somatic scores was also reported in a prospective, comparative survey by Appak et al. (2017) on children with constipation between 4 and 18 years of age (n=32) and 'healthy controls admitted to a paediatric gastroenterology outpatient clinic' (n=31)(pg.466).The study employed the following child and family assessment tools: Strengths and Difficulties Questionnaire (SDQ), Beck Depression Inventory (BDI), State and Trait Anxiety Inventory and Parental Attitude Research Instrument (PARI).High levels of somatic complaints including recurrent abdominal pain, frequency of micturition and faecal soiling were reported in this study.The study also reported significantly higher scores of anxiety and depression in children and their mothers, compared to healthy children and their mothers.This study has a few limitations which were not reported including small sample sizes and nonrandomization of sampling which increases the risk of bias.
The impact of constipation on the psychological and social wellbeing, and overall HRQOL of children and adolescents is reported in numerous studies (Appak et al., 2017;Kaugars et al., 2010;Kilincaslan et al., 2014;Rajindrajith et al., 2013;Rajindrajith et al., 2016;Rajindrajith et al., 2020;Ranasinghe et al., 2017;Wang et al., 2013).Wang et al.'s (2013) cross-sectional, case-control study on children aged 3 to 6 years of age (n=211) using a Chinese version of the Pediatric Quality of Life Inventory TM , version 4.0 (PEDQL TM 4.0) and Elkhayat et al.'s (2016) cross-sectional, case-control study on children aged 4 to 12 years of age (n=100) using an Arabic versions of the Child Behavior Checklist for 4-18 years old (CBCL/4-18) and the Pediatric Quality of Life Inventory TM , version 4.0 (PEDQL TM 4.0) found that scores for quality of life of children were lower compared to those of children without constipation.Both studies employed non-experimental observational methods with two groups: children diagnosed with constipation and healthy control group.Both studies also demonstrated that children with constipation had significantly higher anxiety levels, sleep disturbances and social problems.The reported limitation to both these studies was the use of a generic HRQOL questionnaire which lacks sensitivity and accuracy, and the small sample size in Elkhayat et al. 's (2016) study.Both studies also reported the probability of lower scores with parent perception of child's HRQOL.Neither study identified nor discussed adjustment of potential confounders.Sleep disturbance in children with constipation is also reported in Yildirim et al.'s (2017) quantitative study into health-related quality of life in school aged children.Kilincaslan et al.'s (2014) survey on children aged between 2 and 6 years (n=124) reported that children in the constipation group (n=65) demonstrated higher levels of psychological issues such as anxiety, depression, aggression, externalising and internalising compared to children with normal intestinal habits (n=59).This is supported by Rajindrajith et al.'s (2020) cross-sectional survey which found that adolescents with constipation demonstrated increased risk of significant emotional, behavioural or internalising issues such as withdrawal, unresponsiveness, anxiety and depression in comparison to healthy adolescents.
Childhood constipation also has adverse psychosocial impact on the school environment of children and adolescents.Kaugars et al.'s (2010) qualitative study on children with chronic constipation (n=8) and their caregivers (n=8) found that 62.5% of children in the study reported that school performance was affected by constipation and faecal incontinence.The children in this study also expressed concerns of using toilets in the school and the negative effect of constipation and faecal incontinence at school.This is supported by Rajindrajith et al. 's (2016) survey on adolescents aged between 13 and 18 years, (n=1807) using four validated instruments: ROME III diagnostic questionnaire for the paediatric functional GI disorders, child maltreatment questionnaire, Child Somatization Inventory and Pediatric Quality of Life Inventory (PedsQL).This study found that faecal incontinence associated with chronic constipation is associated with maltreatment of all forms including sexual, emotional and physical abuse.However, the study is unable to determine the direction of this relationship, if maltreatment is the result or cause of faecal incontinence.The study also found that faecal incontinence increased the likelihood of emotional abuse in school by other children and even teachers due to the faecal odour.This study emphasized the significance of the psychological impact of constipation and faecal incontinence on children and adolescents in terms of poor interaction, social phobia and academic performance.A major limitation highlighted in this study was the lack of physical examination to formally diagnose constipation.In addition, authors in this study failed to identify or discuss adjustment of potential confounders.However, the association of abuse and bullying with childhood constipation is also reported in Liyanarachchi et al.'s (2022) systematic review.The review included 15 articles and 2954 children with constipation reported that stressful life events including parental divorce or separation, severe illness in family and parental job loss, as well as stressful school events such as bullying, moved school, separation with best friend and examination failure were all associated with constipation in children.These findings are also supported by a more recent systematic review with similar findings (Gozali et al., 2023).
Constipation with faecal incontinence has a greater adverse effect on the quality of life of the child when compared to childhood constipation without faecal incontinence (Kovacic et al., 2015).This prospective study employed five validated instruments: PedsQL -Parent Report, PedsQL -Family Impact Module (FIM), Functional Disability Inventory (FDI) -Parent Version, Pediatric Inventory for Parents (PIP), and Pediatric Symptom checklist (PSC) -Parent Report.The study included families of children aged between 2 to 18 (n=410) found that quality of life scores worsened as the children's ages increased.Consequently, adolescents with constipation and faecal incontinence demonstrated the lowest scores.A limitation of this study was the use of parent-report of child's HRQOL which may result in lower scores and which may be influenced by parental confounders such as their psycho-emotional status, level of stress or other medical conditions.Another limitation identified was the generic HRQOL questionnaire which may lack sensitivity and accuracy.There is also a financial impact associated with childhood constipation.Constipation with faecal incontinence has a significant impact on families in terms of increased cost and time spent on laundry secondary to soiling and faecal incontinence (Kaugars et al., 2010;Thompson et al., 2021a).There is also a significant cost impact associated with the utilisation of health care services such as emergency department (Choung et al., 2011;MacGeorge et al., 2018), behavioural therapy and prescriptions (Kaugars et al., 2010;Liem et al., 2009;Thompson et al., 2021a).Choung et al.'s (2011) nested case-control study on 5,718 children, adolescents and young adults aged between 5 to 21 years of age reported that the mean medical costs for children with constipation were four times more than children without constipation (p=0.055) and anxiety in children with constipation resulted in a 348% increase in inpatient cost (Choung et al., 2011).Childhood constipation also has an indirect cost impact through the days lost at work for the parents (Liem et al., 2009).
Recurrent constipation as a result of treatment failures has a significant effect on the quality of life of the child's parents and family (Dolgun et al., 2013;Elkhayat et al., 2016;Klages et al., 2017;Thompson et al., 2021b;Wang et al., 2013), resulting in conflict within family members (Kaugars et al., 2010).Parents and families of children with constipation have significantly lower quality of life scores in several aspects including physical, emotional, social, daily activity and relationship (Wang et al., 2013).This is supported by Klages et al.'s (2017) study on caregivers of children aged between 2 and 18 using the Parental Opinion of Pediatric FC (POOPC) (Silverman et al., 2015) which found that caregivers of children with constipation reported high levels of disease burden, distress and psychosocial problems.The study also found that caregivers were dissatisfied with management by healthcare providers which resulted in poor adherence to prescribed treatment.This supports findings from other studies including reports of parental anxiety, frustration, and mistrust of healthcare providers (Kovacic et al., 2015) and Thompson et al.'s (2021b) qualitative study on parental experiences of caring for children with constipation which reported that parents expressed frustration and dissatisfaction with the care received in terms of dismissive and insensitive attitude of care providers, as well as inadequate care, support and information provided.
A review of current literature has highlighted that children with chronic constipation have high levels of behavioural problems such as withdrawal, anxiety, depression, aggression, externalising and internalising.Childhood constipation also has an adverse effect on the quality of life of children and their families, affecting their physical, emotional, social and school life, as well as daily activity and relationship.Parents have expressed anxiety and frustration, as well as dissatisfaction and distrust of healthcare professionals.To date, there has been no studies done to identify the psychosocial implication of childhood constipation on children and their families in Ireland.
The burden of chronic illness is one of the key focuses in the recently published Sláintecare Reports in Ireland, highlighting the need to reform the model of care of children and chronic conditions (Houses of the Oireachtas, 2017).
Therefore, addressing and identifying the impact of childhood constipation on children and their family is crucial to current needs and can be aligned with Sláintecare's vision to improve child health and wellbeing services (Houses of the Oireachtas, 2017).In addition, a recent study has highlighted constipation in children and young people as one of the highest-ranking priorities of research across the UK and Ireland (Cathie et al., 2022).
A preliminary search of databases demonstrated an increasing interest in childhood constipation in recent years.The search was conducted through Cochrane Library on Systematic Reviews, Health Research Board (HRB) Open Research and Joanna Briggs Institute (JBI) Evidence Synthesis, as well as UCD Library Onesearch and Google Scholar where several reviews on constipation were identified.There were 6 reviews registered in PROSPERO: 30 systematic reviews and 2 scoping reviews in Google Scholar and one in HRB Open Research.The majority of all the reviews were focused on pharmacological and non-pharmacological treatments.There were three reviews identified with similar elements: Belsey et al.'s (2010) systematic review is focused on impact on quality of life in adults and children with constipation; Vriesman et al.'s (2019) systematic review is focused solely on the quality of life of children; Thompson et al.'s (2021a) systematic review is focused on experiences and information needs of parents.There are no recent reviews focused on the psychosocial implications of childhood constipation on children or the families of children with constipation.Childhood constipation is a complex health problem that has an adverse effect on multi-dimensional aspects of their life.Therefore, there is a need to identify the extent of these effects on the lives of children.In addition, the identification of how childhood constipation affects the wellbeing of the families is also crucial as the well-being of the child is dependent on family well-being (Newland, 2015).

Aims and objectives
This scoping review aims to identify and explore all current and available literature on the psychosocial implication of childhood constipation on the child and their family.Childhood constipation has a significant impact on multiple aspects of the child and their family's lives.Therefore, this methodology's broad approach will be appropriate and useful to map all available evidence from a heterogeneous source, clarify key concepts and identify gaps in the literature on the topic (Tricco et al., 2018).Scoping reviews are inherently flexible in its methodology allowing for the systematic and diverse search, including grey literature and Google scholar (Peterson et al., 2017:13).Therefore, it is suitable when exploring a complex and multi-dimensional concept such as constipation in children.The objective guiding this scoping review will be to: 1. Explore all available literature regarding the psychosocial implication of childhood constipation on children and families by identifying, critically appraising and synthesising relevant literature.
2. Describe the type and nature of available and current studies on the psychosocial implication of childhood constipation on the child and their families, the challenges they encounter, their views regarding support received; ways to improve psychosocial support.
3. Develop an understanding of the psychosocial implications that childhood constipation has on children and their families.
4. Guide the focus of subsequent research into this area.

Methods
This scoping review will be guided by the six stages of Arksey Population: This scoping review will focus on the psychosocial implication of childhood constipation among children and their families.Therefore, the review will include studies that consider the psychosocial implication from the perspective of children (aged below 18 years living with constipation), and their families including biological and adoptive parents; siblings; formal and informal caregivers; guardians and foster parents that form part of the family unit.

Concept:
The concept of interest is the psychosocial implication of childhood constipation on children and their families.Psychosocial in health sciences incorporates mental and social well-being of the individual (Larson, 1996).For the purpose of this research, psychosocial health will be explored on the individual level referring to the effects of physical and biological events or stressors on the psychological, mental and social life experiences (Peter et al., 2022).This includes the direct and indirect psychosocial impacts of childhood constipation on children and their family members.How these impacts are measured (e.g. using validated screening or measurement tools) and experience studies will also be mapped.

Context:
The context of this scoping review is childhood constipation.The review will be limited to children under the age of 18 years experiencing primary or functional constipation.
No limitation will be placed on geographical locations as the objective is to explore all available literature regarding the psychosocial impact of childhood constipation.The search will be limited to English language articles as this is the primary language of researchers and due to time, cost and translation constraints.There have been reports regarding the potential of excluding vital evidence and language bias when limiting reviews to English-language studies (Boland et al., 2017).However, the evidence is inconclusive as some studies have demonstrated limited evidence of bias when limiting language in systematic reviews and meta-analysis (Dobrescu et al., 2021;Morrison et al., 2012).In cognisant of this, the limitation to English language articles will be reported in the scoping review.
Studies for inclusion in this scoping review are primary studies including quantitative, qualitative and mixed-methods/ multi-methods that explore the psychosocial implications of childhood constipation on children and their families.At the first stage of identifying relevant studies, abstract and full-text will be considered in order to ensure a wide capture of all available relevant studies (Peters et al., 2022).Literature that is not primary studies such as case studies or reports, expert opinions, editorials and literature reviews will be excluded.

Stage 2: Identifying relevant studies
Constipation has multifactorial contributing factors including lifestyle, child development issues, and psychological and behavioural disorders.It also has an adverse effect on multi-dimensional aspects of the life of the child and their family.Therefore, a comprehensive search of electronic databases will include literature from allied healthcare disciplines including PUBMED, CINAHL, ASSIA, Psycinfo and Cochrane Library.Grey literature including 'OpenGray' and Google Scholar will also be searched to ensure a comprehensive search.The literature will also be supplemented by hand searching reference lists of included articles.
The university librarian (DS) was consulted to ensure the development of an extensive and comprehensive search strategy.
The role of librarians in the development of systematic and scoping reviews is increasingly recognized as being invaluable.
It is recommended that librarians are consulted at early stages especially at stage 1 and 2 of scoping reviews to maximise rigour and validity of the review (Morris et al., 2016).The university librarian's (DS) consultation commenced with the identification of key words and index terms of the major elements within the PCC framework -childhood constipation, children, families, and psychosocial implication.All possible synonymous words and matching index terms using controlled vocabulary were identified using synonym and thesaurus software tool as well as MeSH tool in PUBMED and Subject Headings in CINAHL to ensure all relevant articles will be included (Bramer et al., 2018).To further broaden the search, truncation was used.Once syntax appropriate to each database including parentheses was refined, Boolean operators and field codes were employed (Bramer et al., 2018).Boolean search strings by keywords and subject headings are detailed in Extended data (McCague, 2023).
Once keywords and subject headings are refined, the search strategy can commence and will be guided by the JBI three-step search strategy Peters et al. 's (2022).
1.The first stage involves a preliminary limited search of two databases, PUBMED and CINAHL to identify relevant articles.A full search strategy will be developed from key words identified from titles and abstract, as well as index terms used in the relevant articles.An example of search strategy using PUBMED is available in Extended data (McCague, 2023).
2. The second stage will consist of a search using all identified key words and index terms in the remaining selected databases.
3. Hand searching through reference lists of all selected articles will be performed at this stage.The search strategy stage for scoping reviews is also an iterative process as additional keywords and search terms can be identified during the search process, which will be incorporated into the search strategy (Peters et al., 2022).The complete search strategy and results will be documented and described in detail, including any alterations to demonstrate transparency.The librarian (DS) will again be consulted during this stage to ensure a comprehensive and thorough search.

Stage 3: Study selection
The JBI Reviewers Manual for Scoping Reviews will be employed to guide the study selection process.EndNote 20 will be used to manage bibliographic references where all pertinent literature identified will be saved and organized to enable easy retrieval and generation of the reference list.Covidence will then be used to further manage results of the search by importing and screening articles, extracting data and removal of duplicates (Covidence, 2022).
The process will involve: • 1 st (YM) and 2 nd review author will pre-screen all results from the search strategy independently to identify eligible studies based on title and abstract.
• Pilot testing of random selection of 25 titles and abstracts of selected articles will be performed using Covidence to confirm consistency (Peters et al., 2022).
• Potentially eligible studies that meet all inclusion criteria will undergo detailed full-text screening by the 1 st review author (YM).Uncertainty of articles for inclusion will be screened independently by 2nd review author.
• The 3rd review author will resolve any eligibility disagreements by independently screening selected articles (SS/EF).
The selection process will be described in detail, including the number of articles identified, screened for eligibility, and included and excluded to ensure transparency and replicability (Tricco et al., 2018).Description will be in narrative format as well as presented in a PRISMA flow diagram such as one in Extended Data (McCague, 2023).Justifications will be provided for articles that are excluded.

Stage 4: Charting the data
The data charting process will be undertaken using a recognized tool such as JBI Template Data Extraction Instrument (Peters et al., 2022) to ensure transparency, consistency and reduce bias (see Extended Data, McCague, 2023).This tool will be adapted to meet this scoping review's question and objectives.It will be piloted on a minimum of two randomly selected included articles by two reviewers independently as recommended to ensure consistency (Pollock et al., 2021).Any incongruity in the data charted will result in a revision of the data charting form.All alterations made to the original tool will be documented and described to ensure transparency in reporting.Key information to be collected will include (but not restricted to) author, year of publication, country of origin, study design and methodology, aims and purpose of study, population and sample size, outcomes and key findings of study.The information collated will be charted in a data charting form using Microsoft Excel following data extraction tool templates from JBI (Peters et al., 2022).
Critical appraisal and assessment of selected studies are not prerequisites in scoping reviews (Pollock et al., 2021).However, studies should be systematically and critically appraised to promote trustworthiness and methodological rigour (Levac et al., 2010;Tod et al., 2022).For this purpose, many appraisal tools are specifically designed for various types of studies.These include the JBI critical appraisal tools (Joanna Briggs Institute, 2016), the Critical Appraisal Skills Programme (CASP) (Critical Appraisal Skills Programme, 2022), the Mixed Method Appraisal Tool (MMAT) (Hong et al., 2018) and the Appraisal of Guidelines for Research and Evaluation II (Agree II) (Brouwers et al., 2010).
Stage 5: Collating, summarising and reporting the results Results of the search and screening process will be demonstrated in a PRISMA-ScR flowchart (Tricco et al., 2018).Data will be mapped and presented using the PCC inclusion criteria elements in a tabular presentation (Peters et al., 2022).As data in scoping reviews will be predominantly descriptive, data will be synthesised quantitative and qualitatively.Data such as year and country of publication, population and sample size will be analysed using SPSS Version 24 and described using descriptive statistics.Data will be presented through narrative description as well as visual representations such as tables, pie charts and bubble plots (Pollock et al., 2021) rather than synthesized format as the aim is to present and describe the 'breadth of the literature and identify priority areas' (Westphaln et al., 2021:10).This scoping review will be guided by Peters et al. (2022) three-step process: 1. Perform quantitative descriptive analysis and qualitative thematic analysis.
2. Frame results in the context of the research question, aim and PCC.
3. Frame findings in the context of future studies.
Stage 6: Consultation exercise and dissemination Consultation with key stakeholders is an optional but valuable stage as it is an opportunity to ensure the search strategy adequately includes all appropriate terms as well as to obtain feedback on findings (Roberts et al., 2021).While the involvement of knowledge users is not required at every stage, consultation at early stages can be beneficial (Pollock et al., 2021).Key stakeholders to be consulted will include experts in paediatric constipation, emergency medicine paediatricians, paediatric gastroenterologists, general paediatricians, Advanced Nurse Practitioners and Clinical Nurse Specialists in Paediatric Emergency Departments and Gastroenterology Clinics, General Practitioners (GP), continence nurses and dieticians.
Stakeholders within other allied healthcare disciplines such as sociology, psychology, and behavioural science with an interest in childhood constipation will also be consulted.The Children's Research Network (CRN) of Ireland and Northern Ireland will also be consulted, specifically the Early Childhood Research Group (ECRG) whose aim is to support, connect and inform the early childhood research community.Other stakeholders may include members of the public group, charities and network such as Children's Health Ireland Family Forum, Youth Advisory Council, Prevention and Early Intervention Network, Children's Rights Alliance and Irish Youth Foundation in order to gain a comprehensive insight into the psychosocial impacts of constipation on children and their families.
Findings from the scoping review will be disseminated using various strategies including presentations at national and international conferences as well as through publications in peer-reviewed journals.Findings will also be shared with appropriate groups such as the ECRG at CRN which has members that encompass a wide variety of individuals including academics and non-academics in the community, voluntary and social enterprise bodies, and government and statutory bodies.This will assist in a wide dissemination of the scoping review findings.In addition, findings from the review will be presented to appropriate key stakeholders and HSCPs involved in the management of the paediatric population in acute and non-acute settings nationally.

Study status
At the time of publication, this study is at the stage of preliminary searches of databases.

Discussion
There is a growing recognition that childhood constipation is an increasing global health problem which results in significant burden on the child and their family, health services, society and economy.Studies to date have identified that childhood constipation has a significant implication on health-related quality of life on the children and their families, affecting multiple domains of children and their families' lives including physical, emotional, school and psychosocial, as well as daily activity and relationship.
To date, no studies have identified the psychosocial implication of childhood constipation on children and their families in Ireland.Therefore, there is a need for a systematic scoping review to identify and explore all available evidence regarding the psychosocial implication of childhood constipation on the children and their families, as well as to identify gaps in the literature.Findings from the review will be used to direct the focus of subsequent research into childhood constipation in Ireland.
This protocol has been developed to guide a scoping review into the impact of childhood constipation on children and their families.Scoping reviews are inclined to be iterative especially in the search strategy, data extraction and data presentation stages, which can often result in deviance from the protocol (Peters et al., 2022).This is acceptable and recommended to promote the development of a thorough, systematic and comprehensive review.To ensure transparency and rigour, all amendments will be clearly documented and described.
This project contains the following extended data: The psychosocial implication of childhood constipation on the children and family: A scoping review protocol.
To identify and explore all current and available literature on the psychosocial implication of childhood constipation on the child and their family, the authors developed this study protocol, titled" The psychosocial implication of childhood constipation on the children and family: A scoping review protocol."This study is of great importance, as there is currently a tendency to include the approach of psychosocial problems in the initial management of children and adolescents with Constipation.

Abstract. Clearly described
Introduction.The authors, with an adequate literature citation, address a wide range of problems related to Constipation in children and adolescents, such as environmental factors, stressful life events, abuse, bullying, punishment, interaction with parents, alcoholism, illness within the family, anxiety and depression, sleep disturbance, painful defecation, withholding behavior.These topics are fully experienced in a clinic that treats functional gastrointestinal diseases, especially Constipation.
However, in epidemiological data, "Despite this, it is often poorly recognized, inadequately treated," deserves better consideration.Functional Constipation is perfectly defined in the Rome II, III, and IV Criteria, and the treatments are not inadequate but face a series of problems linked to adherence.
Relative to prevalence, In 2018, a systematic review and meta-analysis including 35 countries defined a pooled prevalence of 9.5%, with a similar prevalence in boys (8.6%) and girls (8.9%) but with a higher prevalence of 17.5% in children under four years (Koppen et al., 2018).Ref-1 Concerning Overweight/Obesity, the potential association between FC and overweight and obesity, the statement of reduced average weight and height in children with chronic Constipation when compared to normal children is controversial, as there are a large number of studies favoring or denying this association.First, Koppen et al. (2016) included eight studies, and due to the heterogeneity of the study designs, they could not confirm the association between overweight/obesity and FC.However, other studies revealed the possible association between FC and excessive body weight.Second, a more recent systematic review and meta-analysis (Lazarus et al., 2022) evaluated eighteen studies involving 33,410 children and concluded that FC correlates with the prevalence of overweight and obesity.Ref-2, 3 It was related to parents, home stressors, and bullying.In 2022 a systematic review included 15 articles (2954 children) with FC.It defined child maltreatment, divorce/separation of parents, severe illness in the family, and parental job loss as home stressors.In the same way, bullying, change in school, separation from the best friend, and failure on examination as school-related stressors were associated with childhood constipation (Liyanarachchi et al., 2022).
A recent good-quality systematic review of eleven studies evaluated the relationship between psychological stress and pediatric Functional Constipation.Similarly to the previous review, the authors classify psychological stressors into family, school, and related psychological disorders.In conclusion, most studies showed a significant relationship with Constipation, suggesting a collaborative effort between parents, children, and healthcare professionals (Gozali et al., 2023).
relevant references as provided, and have made the relevant amendments and additions accordingly.Our itemised responses to your constructive feedback is detailed below: 1.The term "treated" was amended to "managed" and problems associated with management was expanded upon as recommended (pg.3).
2. Global pooled prevalence added as recommended (pg.4) 3. The association of childhood FC and obesity was added as recommended.This factor was discussed in my methodology chapter as a justification for research from an Irish perspective, in view of recent publications regarding increasing obesity and overweight in children and adolescent in Ireland.(pg.5) 4. The association between stressful life events was expanded upon as recommended.This was a finding in my completed scoping review (pg.7).

Glicia Estevam de Abreu
Center for Children's Urinary Disorders (CEDIMI), Bahiana School of Medicine and Public Health,, Bahia, Brazil This study is very interesting, given that it describes a protocol for research into childhood constipation and its psychosocial implications.
The introduction provides a broad overview of childhood constipation, demonstrating the importance of the topic.However, I believe it is critical to include information about the link between constipation and urinary symptoms.This association, as well as its implications for the child's psychosocial development, has received a lot of attention.
Although the description of the objectives is clear, I recommend mentioning how the articles defined constipation.Although the Rome IV Criteria are the most commonly used diagnostic tool for constipation, studies that do not use this tool are not uncommon.This could lead to misunderstandings.Methods: Nothing to add.
Is the rationale for, and objectives of, the study clearly described?

Is the study design appropriate for the research question? Yes
Are sufficient details of the methods provided to allow replication by others?Yes Are the datasets clearly presented in a useable and accessible format?Yes Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Constipation, Bladder and Bowel dysfunction I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.
The article describes a study protocol for a scoping review which is aimed at answering the research question, "What has been reported about the psychosocial implication of childhood constipation among children and their families?".This is a well written protocol and the review is in an important and under-researched area of child health.I have some recommendations for the authors: Abstract: Please change "can be caused by" to "is associated with" in the following sentence: "Primary or functional constipation (FC) has no known underlying pathology but can be caused by lifestyle, psychological, and behavioural factors." Introduction: I suggest moving paragraph 3 (which describes the prevalence of constipation) to the second paragraph.It would be helpful for readers to know the prevalence before describing the research on possible risk factors and consequences.Is it possible to add prevalence estimates in community samples by age group?Does the prevalence of childhood constipation increase or decrease with age, or remain constant?
Paragraph 2: there is epidemiological research (e.g. in the ALSPAC cohort) that is missing on early childhood psychosocial risk factors for constipation (e.g.stressful life events, child behaviour/emotional problems, exposure to maternal psychopathology).This research is relevant to the content of this paragraph.
Paragraph 4 describes associations between constipation, and reduced height and weight, in addition to higher somatic scores.It also describes a study by Appak et al (2017) that compared depression, anxiety and emotional/behaviour problems in children with constipation and healthy controls.The same study is mentioned again in paragraph 5 which begins: "Chronic constipation also has a significant psychosocial impact on children and adolescents".I suggest mentioning these findings relating to depression, anxiety and emotional/behaviour problems in paragraph 5.
A couple of limitations of the Did this study adjust for potential confounders that might provide an alternative explanation for the observed association?
The cost implications of constipation for families and the burden on healthcare services could be expanded.The review could also mention the importance of early identification and intervention for paediatric constipation to prevent it from becoming chronic and having secondary impacts on the child and family.
In Aims and Objectives it would be helpful to define the term 'psychosocial' and to specify the domains that will be explored.

Methods
Please could you change the review question to "What are the psychosocial impacts of childhood constipation on children and their families?" Stage 6: Consultation Exercise and Dissemination: A useful addition to your stakeholders would be charities involved in supporting children and young people affected by chronic constipation and continence issues, and their families.Health professionals may not have insights into the full range of psychosocial impacts of constipation.
Is the rationale for, and objectives of, the study clearly described?Yes Is the study design appropriate for the research question?Yes

Are sufficient details of the methods provided to allow replication by others? Yes
Are the datasets clearly presented in a useable and accessible format?

Not applicable
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Paediatric incontinence; developmental psychology; epidemiology; mental health I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
recommended as this was very relevant to the content of this paragraph.(pg.4) 4. Findings relating to depression, anxiety and emotional/behaviour problems were added to the discussion regarding the significant psychosocial impact on children and adolescent as recommended (pg.4) 5. Limitations such as study design, sample size, risk of bias and confounding variables reported in other studies as recommended (pg. 4,5,6) 6. Lack of adjustment for confounders reported as suggested (pg.6) 7. Discussion on cost factors and importance of early identification and intervention for paediatric constipation to prevent it from becoming chronic and having secondary impacts on the child and family expanded upon as recommended (pg.6,7) 8. The term psychosocial and domains to be explored expanded upon as recommended (pg.11) 9. Question amended as recommended (pg.9) 10.Additional stakeholders such as charities involved in supporting children and young people affected by chronic constipation and continence issues, and their families expanded upon as recommended (pg.14) Westphaln et al. (2021)(Arksey & O'Malley, 2005)and the updated and refined version byPeters et al. (2022).In order to ensure rigour in reporting, the review will be carried out and reported using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Review (PRISMA-ScR)(Tricco et al., 2018).The six stages of the review are described as follows.Stage 1: Identifying the research questionThe first stage in the Arksey and O'Malley's Framework  (2005)is the formulation of a research question that will address the key elements of the review and form the foundation of the search strategy.The Population, Concept and Context (PCC) framework is recommended for scoping reviews as it provides guidance in the formation of 'clear and meaningful' review questions and inclusion/exclusion criteria The review question and objectives will determine eligibility criteria for this scoping review, as it will direct the development of inclusion and exclusion criteria(Pollock et al., 2021).The PCC framework was employed to guide the development of the inclusion and exclusion criteria and the search strategy(Peters et al., 2022).All inclusion and exclusion criteria for this scoping review are described in Table1, adapted from Boland, Cherry and Dickson's (2017:82) screening and selection tool.Westphaln et al. (2021)has suggested that this stage requires a broad and iterative approach to refining the review questions, reviewing aim and objectives, and specifying elements of PCC.
(Westphaln et al., 2021)ers et al.,  :2122)).The review question should also be aligned to the review aim and purpose(Westphaln et al., 2021), with a broad scope to ensure extensive capture of relevant references(Arksey & O'Malley, 2005).The review question formulated using the recommended PCC framework in consultation with research supervisors is as follows:"What has been reported about the psychosocial implication of childhood constipation among children and their families?"Eligibility Criteria.

Table 1 . Inclusion and exclusion criteria of study selection.
• Boolean search strings by keywords and subject headings PUBMED and Boolean search strings by keywords and subject headings CINAHL Appak et al. study are mentioned:small sample sizes and nonrandomization of sampling.Please describe the limitations of the other studies e.g.study design, sample size, risk of bias.Did the studies adjust for confounders?If so, what were they?Some studies (e.g.Wang et al. 2013) are described as a "cross-sectional, case-control study".Please explain this study design.Rajindrajith et al.'s (2016) survey found that faecal incontinence associated with chronic constipation increased the likelihood of emotional abuse in school by other children and teachers.