Bowel Management Protocols in Pediatric Chronic Constipation and Complex Colorectal Dysfunction: A Systematic Review of Sennoside Dosing, Evacuation Strategies, and Radiologic Monitoring.

To synthesize evidence on pediatric bowel rehabilitation protocols for chronic constipation and complex colorectal dysfunction, with emphasis on sennoside dosing, disimpaction, mechanical evacuation, radiologic monitoring, outcomes, and adverse events, we conducted a systematic review following PRISMA 2020 and registered it in PROSPERO (CRD420261350563). PubMed/MEDLINE, Embase, Scopus, CENTRAL, LILACS, and SciELO were searched through March 10, 2026. Eligible studies included patients aged 0-21 years with functional or idiopathic constipation, constipation after anorectal malformation repair, or neurogenic bowel dysfunction, and provided extractable mechanicalevacuation data; patients were treated with sennosides, enemas, transanal irrigation, antegrade continence enemas, or surgical escalation. Etiologic groups were interpreted separately because fecal soiling and incontinence do not have a uniform pathophysiologic meaning across functional, anatomic, and neurogenic disorders. Risk of bias was assessed using RoB 2, ROBINS-I, or Joanna Briggs Institute tools, and certainty was evaluated with GRADE. Thirty-two records were identified. After duplicate removal, 31 full-text reports were assessed, and 21 studies were included in the qualitative synthesis; of these, 16 contributed quantitative protocol data. Common components included initial assessment, disimpaction, individualized titration, and objective confirmation of colonic emptying. Sennoside doses ranged from 0.45-0.9 mg/kg/day to high, individualized mg/day regimens, whereas transanal irrigation commonly uses 10-20 mL/kg or 300-700 mL. Radiography was primarily used to monitor therapeutic response. GRADE certainty was moderate for clinical-radiologic success after repair of anorectal malformations, low for most medical and mechanical protocol outcomes, and very low for surgical escalation. Reported adverse events included abdominal cramping and contact perineal injury among diapered children. Pediatric bowel rehabilitation should be stepwise, individualized, and etiology-sensitive; however, the certainty of the evidence remains limited by observational study designs and heterogeneous definitions, underscoring the need for prospective multicenter standardization.