Introduction
Functional constipation is a common gastrointestinal disorder that affects children globally. Based on the available data, it has a pooled prevalence of 9.5%.1 Constipation is a frequent cause of emergency department visits.2 It can result in substantial use of clinical resources in outpatient departments, particularly among children.3 Additionally, constipation can significantly impact public funds through annual health budgets, directly and indirectly.4
Several guidelines describe the management of childhood constipation.5–7 Even with optimal management, about one-third of children are deemed to have therapy-resistant constipation.8 Although childhood functional constipation is clearly defined using the Rome criteria, there is no such definition for children not responding to optimal management.9 Several authors have defined therapy-resistant constipation using the duration of unresponsiveness to medical management varying from 3 months to 2 years without clear consensus.5 10 In addition, clinicians and researchers use the terms ‘refractory’ and ‘intractable’ interchangeably, complicating the definition of therapy-resistant constipation.
Therapy-resistant constipation has long-term physical and psychological complications.11–13 In addition, some children with therapy-resistant constipation undergo invasive diagnostic tests such as barium enema, defecography, anorectal and/or colorectal manometry. The majority of these children need (a combination of) oral laxatives, enemas or transanal irrigation. A smaller proportion requires even needs surgical interventions, such as sacral neuromodulation, antegrade continence enema, the formation of diversion stomas and surgical resection of the bowel, or subtotal colectomy, with ileorectal anastomosis, all interventions which have significant morbidity and a high incidence of complications.14 Therefore, it is imperative to clearly define therapy-resistant constipation to ensure consistent deployment of therapies to this group and consistent understanding of the goals and outcomes of therapies in these circumstances. Against this backdrop, we aimed to conduct a systematic review to determine how interventional studies define the condition and propose a way forward for an internationally accepted definition.