American Academy of Pediatrics – Section on Emergency Medicine and the Canadian Association of Emergency Physicians

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December 2, 2022

Do not obtain abdominal radiographs for suspected constipation.

Functional constipation and nonspecific, generalized abdominal pain are common presenting complaints for children in emergency departments. Constipation is a clinical diagnosis and does not require testing, yet many of these children receive an abdominal radiograph. However, subjectivity and lack of standardization result in poor sensitivity and specificity of abdominal radiographs to diagnose constipation. Use of abdominal radiographs to diagnose constipation has been associated with increased diagnostic error. Clinical guidelines recommend against obtaining routine abdominal radiographs in patients with clinical diagnosis of functional constipation. The diagnosis of constipation or fecal impaction should be made primarily by history and physical examination, augmented by a digital rectal examination when indicated.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items
on this list or their individual situation should consult their physician.

How The List Was Created

The American Academy of Pediatrics Section on Emergency Medicine (AAP SOEM) Committee on Quality Transformation (COQT) assembled a task force to oversee the creation of a Pediatric Emergency Medicine Choosing Wisely list. The task force first collected suggested recommendations from a diverse group of ED providers (physicians, nurses, and advanced practice providers) from six academic pediatric EDs to gather an initial list of frequently overused and/or avoidable tests and interventions. Task force members independently scored these items on an anchored rating scale based on each item’s frequency of overuse in a typical ED shift, the evidence for lack of efficacy, and the potential harm associated with overuse. The scores were discussed, and consensus was reached for the top 25 ranked items. Next, this list of 25 proposed items was sent to all COQT members in a survey format. The COQT member survey respondents selected which 10 items they believed should be included in the Choosing Wisely list. The task force then ranked the selected items based on the frequency of selection by COQT members. The five top-ranked items that were not duplicative of items on other subspecialty Choosing Wisely lists were submitted and approved by AAP SOEM leadership. The list of five final items with summary evidence was subsequently forwarded for peer review to relevant expert AAP Committee, Council, and Section leadership. The AAP Board of Directors and Executive Committee granted final approval of this list.


Freedman SB, Rodean J, Hall M, et al. Delayed diagnoses in children with constipation: multicenter retrospective cohort study. J Pediatr. 2017;186:87-94.e16. DOI:

Pensabene L, Buonomo C, Fishman L, Chitkara D, Nurko S. Lack of utility of abdominal x-rays in the evaluation of children with constipation: Comparison of different scoring methods. J Pediatr Gastroenterol Nutr. 2010;51(2):155-159. DOI:

Berger MY, Tabbers MM, Kurver MJ, Boluyt N, Benninga MA. Value of abdominal radiography, colonic transit time, and rectal ultrasound scanning in the diagnosis of idiopathic constipation in children: a systematic review. J Pediatr. 2012;161(1):44–50.e502. DOI:

Tabbers MM, DiLorenzo C, Berger MY, et al. Evaluation and treatment of functional constipation in infants and children: Evidence-based recommendations from ESPGHAN and NASPGHAN. J Pediatr Gastroenterol Nutr. 2014;58(2):258-274. DOI:

Kearney R, Edwards T, Braford M, Klein E. Emergency provider use of plain radiographs in the evaluation of pediatric constipation. Pediatr Emerg Care. 2019;35(9):624-629. DOI: 10.1097/PEC.0000000000001549

Freedman SB, Thull-Freedman J, Manson D, et al. Pediatric abdominal radiograph use, constipation, and significant misdiagnoses. J Pediatr. 2014;164(1):83-88.e2