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Background: Previous systematic reviews have found insufficient and conflicting evidence for an association between the clinical and radiographic diagnosis of functional constipation. Abdominal X-ray is frequently used for the diagnosis of functional constipation in clinical practice. The objective of this study was to evaluate the diagnostic accuracy of abdominal X-ray for the evaluation of functional constipation in children. Results: Three studies were included in the final qualitative analysis. They were heterogeneous in their study design, definition of constipation, and radiologic parameters used to evaluate the abdominal X-rays. Sensitivities ranged from 73–92%, specificities ranged from 26–92%, and diagnostic accuracies ranged from 78–90%. Methods: This study involved a systematic review of English literature published between 2012 and 2022 covering children 2–18 years of age with a diagnosis of functional constipation in whom abdominal X-ray was performed. The databases searched include Medline, Embase, and Scopus. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) guidelines were followed. PROSPERO ID: CRD42022301833. Conclusions: There is insufficient evidence to support the use of abdominal X-ray as part of the diagnostic workup of functional constipation. More methodologically rigorous studies are needed to determine the utility of abdominal X-ray in the evaluation of functional constipation. The diagnosis of functional constipation should be based on history and clinical findings. [ABSTRACT FROM AUTHOR]