Towards a definition of refractory/ therapy-resistant/ intractable constipation in children: A cross-sectional, questionnaire-based, online survey

Abstract

Background
The Rome criteria define childhood functional constipation but do not address refractory constipation. Attempts to define refractory constipation lack consensus. The interchangeable use of “refractory” and “intractable” or “therapy-resistant” constipation and lack of understanding of the therapeutic ceilings before this diagnosis, complicates the definition.

Aim
To conduct an online cross-sectional study among medical professionals and researchers across a range of countries, to propose a consensus definition, terminology and duration of medically unresponsive constipation.

Method
An expert-designed questionnaire was disseminated via Google Forms in a two-stage study over two months targeting pediatric gastroenterology professionals globally and Latin American clinicians with a translated version. The questionnaire had 7 critical questions containing details need to define medically unresponsive constipation. The study protocol was approved by the Ethics Review Panel..

Results
The survey involved 1,079 participants: 87 from various countries in the first phase and 992 from Latin America in the second. There were 619 (57.3%) general pediatricians and 462 (43 %) pediatric gastroenterologists. The preferred term to indicate poorly responding constipation was "therapy-resistant constipation" (47.8%), followed by "refractory constipation" (43.6%). The majority of respondents (92.9%) agreed on considering a time frame for defining refractory constipation, with 37.7% suggesting 2-3 months. Four hundred and sixty seven (43.2%) recommended including failure despite maximum laxative therapy with two agents should be considered as previous therapy failure. Compliance with therapy was deemed essential for successful treatment by 91.1%, assessed through detailed history-taking (47.4%) or medical/pharmacy records (29.4%).

Conclusion
Based on the professional views collected in this study, we propose the term ‘Therapy-resistant constipation’ and it can be defined as constipation that is not responding to a maximum dose of at least 2 laxatives of different classes for a minimum of 3 months with good compliance in a secondary, or tertiary care facility.