functional constipation ( fc ) is common in children with an estimated prevalence of 3% worldwide ( 1 ) . the most common pathogenesis of fc is a vicious cycle that begins with painful defecation and leads to stool - withholding behavior as a result ( 2 ) . identifying the factors that lead to painful defecation in early childhood is important in the prevention of fc . over 2 million children attend daycare centers in the republic of korea , for an average 5 - 9 hours per day ( 3 ) . however , no studies have reported the precipitating factors of fc related to daycare centers . previous reports on fc during early childhood involved children who visited a pediatric clinic with a complaint of constipation or other disorder ( 4 ) . our objective was to determine the risk factors associated with the development of fc in young childhood attending daycare centers . a cross - sectional survey using a questionnaire was conducted in children aged 25 to 84 months from 3 randomly selected daycare centers in january 2016 . the questionnaire developed by our institute contained 40 items about demographic characteristics , bowel habits , lifestyles and eating habits associated with fc at home and in daycare centers . data were analyzed with spss , version 17.0 ( spss , chicago , il , usa ) . the items in a questionnaire were compared in the constipated and non - constipated groups using a  analysis and student 's t - test . this study was approved by the institutional review board ( hirb-2015 - 11 ) and informed consent was obtained from the caregivers of children in the study . this study was approved by the institutional review board ( hirb-2015 - 11 ) and informed consent was obtained from the caregivers of children in the study . data were collected from a questionnaire completed by caregivers , who were mostly mothers ( 91.2% ) . a total of 217 children were enrolled ; 2 were excluded because of the underlying disease ( 1 had an anorectal malformation and 1 had cerebral palsy ) , and 3 submitted an incomplete questionnaire . a total of 212 children ( boys : 111 [ 53.11% ] , mean age : 54.5 months , standard deviation [ sd ] 15.1 months ) were included ( table 1 ) . of these , 18 children ( 8.5% ) fulfilled the rome iii criteria for fc ( table 1 ) . values are mean  sd or no./total no.(% ) . in the analysis of clinical characteristics , the 2 groups did not show significant differences in age ( p = 0.656 ) , gender ( p = 0.782 ) , weight ( p = 0.307 ) , height ( p = 0.820 ) , birth week ( p = 0.964 ) , and the number of mothers with a university degree ( p = 0.521 ) ( table 1 ) . maternal history of constipation ( p = 0.011 ) and parental recognition of a child 's constipation ( p = 0.000 ) were significantly associated with fc ( table 1 ) . seventeen ( 77.3% ) of 22 parents who recognized the child 's fc refused to treat the child at clinic , because modification of eating habits might be adequate to treat the fc , and previous short - term treatment of fc at a clinic was not satisfactory . the two groups showed no significant differences in age of toilet training ( p = 0.744 ) or history of difficult toilet training ( p = 0.595 ) ( table 1 ) . however , the constipated group reported a significantly higher rate of painful defecation before age 1 ( p = 0.000 ) and during toilet training ( p = 0.000 ) than the non - constipated group ( table 1 ) . in the analysis using the rome iii criteria , the constipated group was significantly associated with all items ( p = 0.000 ) , and the most common complaint was pain during defecation ( 55.6% ) ( table 2 ) . a history of rectal bleeding ( p = 0.008 ) , withholding ( p = 0.021 ) and hard stools ( p = 0.003 ) were also significantly associated with fc ( table 2 ) . the constipated group was significantly associated with 2 hours or less of outdoor play activities per day ( p = 0.044 ) , entry into daycare centers before 24 months age ( p = 0.02 ) , 6 hours or more of attendance at daycare centers per day ( p = 0.049 ) , and no or difficult defecation at daycare center ( p = 0.000 ) ( table 3 ) . when analyzed for feeding history , the constipated group was significantly associated with breastfeeding for less than 6 months ( p = 0.033 ) , 3 meals or less a day ( p = 0.021 ) , 500 ml or less of water intake per day ( p = 0.002 ) , no meat consumption ( p = 0.000 ) , and 3 or fewer servings of fruits and vegetables per day ( p = 0.046 ) ( table 3 ) . p < 0.05 ; sedentary activities included watching tv or playing with cell phone ; water intake excluded milk and liquids . multivariate logistic regression analyses revealed that maternal history of constipation ( p = 0.026 ) , history of painful defecation before age 1 ( p = 0.045 ) , history of painful defecation during toilet training ( p = 0.014 ) , no or difficult defecation at the daycare center ( p = 0.000 ) , no meat consumption ( p = 0.036 ) , and 500 ml or less of water intake per day ( p = 0.049 ) were statistically significant predictors of fc in young children ( table 4 ) . p < 0.05 ; sedentary activities included watching tv or playing with cell phone ; water intake excluded milk and liquids . this study showed that maternal history of constipation , early experience of painful defecation , no or difficult defecation at the daycare center , drinking 500 ml or less of water per day , and no meat consumption were risk factors for fc in early childhood , opposed to external factors such as the age of toilet training , the birth of siblings or environmental change ( 7 ) . in agreement with previous studies , our data showed that breastfeeding for less than 6 months , entry into daycare before 24 months age and eating fewer meals with fruits and vegetables were important factors associated with fc in young children ( 89 ) . to our knowledge , this is the first study to assess factors of fc related to daycare centers in early childhood . there have been no reports that children who spent 6 or more hours per day at a daycare center were more likely to present with fc . early recognition and modification of these risk factors are important , because fc associated with daycare centers will continue through middle - school years ( 11 ) . some studies have reported that the earlier a child entered daycare , the more pronounced the socio - behavioral problems ( 12 ) . those who entered into daycare before 24 months age were more likely to present with fc , rather than before 6 months and 12 months age in this study . this result might be related with bowel habit change associated with toilet training . in this study , no and difficult defecation at the daycare center were the predictors of fc with high odds ratio in logistic regression analysis . however , a small number of subjects in this study could lead to an overestimation of odds ratio , because no and difficult defecation at the daycare can be the result and the risk for fc ( 10 ) . to calculate the accurate odds ratio , drinking 500 ml or less of water per day was also a predictor of fc , whereas the amount of water intake at the daycare center was not significantly associated with fc in this study . the results for this item in the questionnaire might be incorrect , because 88 caregivers ( 42% ) reported they did not know . although there is no evidence that extra water intake is useful to treat fc , caregivers need to be concerned about a child 's water intake ( 13 ) . this study is meaningful because we assessed the factors predisposing to fc in daycare centers , where most children spend much of the day . these results could be used in behavioral therapy to prevent fc and to modify precipitating factors in early childhood . notably , this study assessed healthy children in a public environment , while previous studies reported the clinical characteristics of fc in children who visited the hospital with the complaint of constipation or other disorders ( 14 ) . among the items in the questionnaire , the refusal to seek treatment despite recognition of a child 's constipation is meaningful to pediatricians . public education about managing and treating fc is needed and parents must be advised that medication , if needed , could be helpful in an individualized regimen that can vary from months to years . a limitation of the study was the lack of accurate data on the amount of water , meat , and fiber intake provided by 24-hour dietary recall . the item of ' afraid to use the toilet at daycare center ' can be added in the questionnaire for analyzing the bowel habits at daycare centers . to clarify the precipitating factors for fc at daycare centers , multicenter studies with a larger number of children and additional surveys of daycare teachers will be needed . our study determined the predisposing factors for fc in early childhood among the lifestyle and eating habits in the home and in daycare centers . the findings of this study can guide parents , daycare teachers , and clinicians in prevention , early recognition and early intervention for the risk factors associated with fc in young children .
our objective was to determine the risk factors associated with the development of functional constipation ( fc ) in young children attending daycare centers . a cross - sectional survey using a questionnaire based on the rome iii criteria 
 was conducted in children aged 25 to 84 months from 3 randomly selected daycare centers in january 2016 . 
 the items in a questionnaire were statistically compared in the constipated and non - constipated groups . 
 a total of 212 children were included and fc was found in 8.5% . 
 multivariate logistic regression analyses revealed that maternal history of constipation ( odds ratio [ or ] = 4.1 , 95% confidence interval [ ci ] 1.2 - 13.9 ) , history of painful defecation before age 1 ( or = 10.4 , 95% ci 1.1 - 101.3 ) , history of painful defecation during toilet training ( or = 28.9 , 95% ci 1.9 - 423.8 ) , no or difficult defecation at a daycare center ( or = 5,804.6 , 95% ci 134.4 - 250,718.4 ) , no meat consumption ( or = 10.1 , 95% ci 1.2 - 88.1 ) , and 500 ml or less of water intake per day ( or = 9.9 , 95% ci 0.9 - 99.5 ) were powerful predictors of fc in young children ( p < 0.05 ) . 
 additionally , the constipated group was significantly associated with 2 hours or less of outdoor play activities per day , entry into daycare centers before 24 months age , 6 hours or more of attendance at a daycare center per day , breastfeeding for less than 6 months , 3 meals or less per day , and 3 or fewer servings of fruits and vegetables per day ( p < 0.05 ) . 
 the findings of this study can guide parents , daycare teachers , and clinicians in prevention , early recognition and early intervention for the risk factors associated with fc in young children .