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

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 2 months targeting paediatric gastroenterology professionals globally and Latin American clinicians with a translated version. The questionnaire had seven critical questions containing details needed to define medically unresponsive constipation. The study protocol was approved by the ethics review panel.

Results: The survey involved 1079 participants: 87 from various countries in the first phase and 992 from Latin America in the second. There were 619 (57.3%) general paediatricians and 462 (43 %) paediatric 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. 467 (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 two laxatives of different classes for a minimum of 3 months with good compliance in a secondary or tertiary care facility.