Julie Khlevner, MD

Shared Decision-Making, Adherence, and Future Directions in Pediatric IBS-C and Functional Constipation

An expert outlines communication and shared decision-making strategies that support adherence and trust, and describes emerging patient-centered outcomes that are reshaping future care paradigms in pediatric functional constipation and IBS-C.

Long-term success in managing pediatric functional constipation and IBS-C depends heavily on the quality of clinician–family communication and the strength of the therapeutic relationship. Julie Khlevner, MD, identifies early, explicit validation of symptoms and family concerns as one of the most effective strategies for enhancing adherence and reducing frustration. She deliberately frames these disorders as chronic but manageable conditions of gut–brain interaction, shifting expectations away from a rapid cure and toward incremental symptom control, relapse prevention, and improved day-to-day functioning in school and social settings.

Shared decision-making is central to Khlevner’s practice. She engages families and adolescent patients in discussions that account for school schedules, extracurricular commitments, and personally meaningful treatment goals, while carefully explaining the role of each therapeutic component, including medications, toileting routines, dietary changes, and behavioral strategies. By preparing families for variable trajectories and the need for sustained routines, she seeks to reduce premature discontinuation of therapies and to maintain engagement even when progress is gradual rather than dramatic.

Looking ahead, Khlevner describes a field that is increasingly focused on phenotype-driven, individualized care and on broader, patient-centered outcome measures. She notes a shift away from narrow stool frequency metrics toward endpoints such as pain reduction, daily functioning, school participation, sleep quality, and overall health-related quality of life. As future clinical trials and routine practice adopt these outcomes, definitions of treatment success in pediatric functional constipation and IBS-C are likely to evolve, with implications for therapy selection, counseling, and multidisciplinary care models across the spectrum of pediatric disorders of gut–brain interaction.

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Learn how validating families and treating pediatric IBS/constipation as gut–brain disorders boosts adherence and focuses care on daily life.

Heterogeneity, Refractory Symptoms, and Multidimensional Care in Pediatric Functional Constipation and IBS-C

Explore the heterogeneity of pediatric functional constipation and IBS-C, the limitations of one-size-fits-all algorithms, and the importance of integrating dietary, behavioral, and psychosocial interventions alongside pharmacologic therapy.

Despite the availability of numerous therapies, many children with functional constipation or IBS-C remain dissatisfied with treatment outcomes, revealing persistent gaps in standard management strategies. Julie Khlevner, MD, attributes these challenges to the heterogeneity of disorders of gut–brain interaction, which often involve comorbid conditions, refractory symptoms, extraintestinal manifestations, and significant impacts on quality of life. In her view, linear, one-size-fits-all algorithms frequently underperform in this context, because they do not fully account for the diverse symptom drivers and multifactorial pathophysiology present in individual patients.

To address this complexity, Khlevner highlights the value of a multidimensional, biopsychosocial approach. For functional constipation, she describes combining pharmacologic and nonpharmacologic treatments to create predictable, comfortable stooling patterns while simultaneously targeting behavioral contributors such as withholding and dysfunctional toileting. Practical behavioral strategies—including scheduled toilet sitting, proper positioning, and reinforcement techniques—are paired with individualized dietary recommendations that focus on age-appropriate fiber intake and hydration and on identifying specific dietary triggers, without resorting to overly restrictive or burdensome diets.

Khlevner also underscores the importance of psychosocial and lifestyle factors, including stress, coping patterns, social media use, and sleep, which can influence symptom severity and responsiveness to interventions in both functional constipation and IBS-C. When indicated, she incorporates behavioral health support such as cognitive behavioral therapy and gut-directed interventions, particularly for patients with marked pain amplification or hypervigilance. Although she acknowledges that access to interdisciplinary care remains a significant challenge, she views integrated models that bring together medical, dietary, and behavioral expertise as critical for optimally managing pediatric disorders of gut–brain interaction.

Validate families, reset expectations, and use shared decisions to manage pediatric constipation and IBS with personalized, functional goals.

Linaclotide in Pediatric IBS-C—Evidence, Indications, and Practical Use

An expert reviews the pediatric IBS-C label expansion for linaclotide, discusses how it addresses historical evidence gaps, and outlines practical considerations for patient selection, counseling, and monitoring.

The pediatric IBS-C label expansion for linaclotide marks a meaningful advance in the treatment of disorders of gut–brain interaction in children. Julie Khlevner, MD, explains that pediatric gastroenterologists have historically relied on a mixture of lifestyle modification, laxatives, dietary interventions, behavioral therapies, and off-label medications extrapolated from adult data. While many patients improve with these measures, a substantial subgroup continues to experience abdominal pain, bloating, and constipation-related symptoms despite optimized conventional therapy. Linaclotide’s pediatric data help fill a longstanding gap by providing an FDA-approved, evidence-based pharmacologic option specifically evaluated in children with IBS-C.

Khlevner notes that pediatric patients with IBS-C often present with a broad symptom complex driven by abdominal pain and visceral hypersensitivity, even when stool frequency is partially addressed. She points out that over-the-counter osmotic laxatives may normalize stool consistency and frequency but frequently fail to adequately treat pain and global IBS symptom burden. Having pediatric-specific efficacy and safety data for linaclotide enables clinicians to counsel families more precisely about dosing, expected response, adverse effects, and monitoring, while supporting more informed shared decision-making among families who may otherwise be hesitant about off-label regimens.

From a practical standpoint, Khlevner stresses that clinicians should confirm current age indications and labeled uses for linaclotide and integrate its use within evidence-based algorithms, including the recently published ESPGHAN and NASPGHAN guidelines for functional constipation, IBS, and functional abdominal pain disorders. She recommends that treatment decisions balance efficacy, safety, tolerability, availability, and feasibility in each case and that responses to any initiated therapy be assessed at defined intervals. This approach is intended to avoid prolonged reliance on ineffective regimens and to ensure that children with persistent functional constipation or IBS-C symptoms can transition efficiently to alternative or adjunct therapies supported by robust pediatric data.

FDA expands linaclotide use for pediatric IBS-C, offering child-specific evidence to treat pain, bloating, and constipation beyond laxatives.

Chronicity, Symptom Variability, and Treatment Expectations in Pediatric Functional Constipation and IBS-C

An expert underscores the importance of early expectation setting around chronicity, symptom variability, and realistic treatment goals for children with functional constipation or IBS-C.

Successful long-term management of pediatric functional constipation and IBS-C requires more than selecting a specific therapy; it depends heavily on how clinicians frame the conditions and set expectations with families. Julie Khlevner, MD, recommends presenting these disorders early as chronic, often relapsing conditions with fluctuating symptom intensity rather than problems that will respond to a rapid or linear cure. She finds that normalizing symptom variability from the outset can help reduce anxiety when symptoms recur, mitigate repeated urgent reassessments, and decrease reliance on unnecessary investigations.

In functional constipation, Khlevner observes that many families expect laxatives to “fix” the problem within weeks, whereas underlying drivers—such as withholding behaviors, altered anorectal sensation, rectal dilation, and dysfunctional toileting patterns—frequently require months to improve. She emphasizes that maintenance therapy often must continue even after stool frequency normalizes, with careful tapering only when appropriate. Without explicit counseling, families may stop treatments prematurely or use medications inconsistently, leading to relapse and a loss of confidence in the care plan.

For IBS-C, Khlevner highlights that outcomes are typically judged by reductions in symptom burden and improvements in daily functioning, not complete symptom resolution. She deliberately distinguishes symptom improvement, functional improvement, and full symptom eradication, and she aligns therapeutic goals through shared decision-making. She also notes that a subset of children will continue to experience symptoms into adulthood, underscoring the importance of planned transition-of-care strategies. Clear, early communication about chronicity, timelines, and realistic targets can preserve adherence and sustain therapeutic alliances over the course of a child’s development.

Learn how realistic expectations, long-term laxative plans, and shared goals improve pediatric constipation and IBS outcomes, reducing relapse anxiety

Julie Khlevner, MD

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