Defining Constipation in Childhood and Adolescence: From Rome, Via Boston, to Paris and …?

Standardization of the definitions of defecation disorders allows comparisons among clinical and research experience throughout the world. Proposals on definition schemata have been published by several groups of specialists over the last few years (1-3). In order to obtain sufficiently wide acceptance and adherence to a definition scheme however, any proposal must be approved by the vast majority of specialists and must have its validity proven in practical terms. Definitions must be broad enough to relate not only to severe cases dealt with in specialty clinics but also to mild disturbances in the bowel habit of healthy children. The interesting proposal (3) of the “Paris Consensus on Childhood Constipation Terminology Group” recently published in The Journal of Pediatric Gastroenterology and Nutrition is a valuable contribution to this issue. The group felt a new proposal was needed because they considered the “current Rome criteria too restrictive.” With the same justification, we would like to propose that the Paris definitions of constipation be reexamined, as they exclude children and adolescents with predominantly hard stools in scybalous, pebble-like or cylindrical cracked form. These patients frequently do not have two or more of the conditions required by the Paris proposal to characterize constipation, namely: (1) fewer than three bowel movements per week; (2) more than one episode of fecal incontinence per week; (3) large stools in the rectum or palpable on abdominal examination; (4) stools so large that they obstruct the toilet; (5) retentive posturing and withholding behavior; (6) painful defecation. It is important to emphasize that some characteristics obtained only by physical examination (especially stools in rectum) as the Paris consensus proposes, although important, are not applicable to community surveys. Further, in our clinical experience, we have observed children with straining which was not accompanied by pain during defecation. Two surveys from Brazil (4, 5), among others, support our opinion. In the first, 1145 school children (median age 8.3 years) were studied and the criteria for diagnosing constipation were the usual elimination of hard scybalous stools and/or straining/pain at defecation. Constipation was detected in 28.8% of the population, of which 66.4% had scybalous stools, 37.9% had straining/painful defecation and 31.2% had soiling (incontinence). By the Paris proposal, many of these children with constipation would not have been diagnosed. During this survey, the children were often uncertain about their stool frequency, and mothers of school children may not have this information, making it difficult to obtain accurate information on stool frequency in this group. Another study was performed among infants who were evaluated at a community well baby clinic (5). The characteristics of the bowel habit for diagnosing constipation were pain and/or straining at defecation and the elimination of hard (scybalous or cylindrical cracked) stools. The prevalence of constipation was 25.1% (69/275) with scybalous stools reported in 44 (63.8%) of the 69 infants with constipation. Only 5.8% of the infants with constipation had fewer than three stools per week. In 8 (5.0%) of the 159 infants under 6 months of age, bowel habits characterized by infrequent stools (interval ≤3 days) but with liquid, soft, or pasty consistency and eliminated without pain or difficulty were observed. These infants were classified as having pseudoconstipation, a definition not covered in either the Rome or Paris proposals (1, 3). Taking into account these above mentioned concerns, we consider that the definition previously suggested by the “Boston working group” (2) is sufficiently broad to be used both in specialized pediatric gastroenterology units and in community settings, since it includes not only mild forms but also severe forms of constipation. The Boston working group suggests that “constipation is a symptom defined by the occurrence of any one of the following, independent of stool frequency: passage of hard, scybalous, pebble-like, or cylindrical cracked stools; straining or painful defecation; passage of large stools that may clog the toilet; or stool frequency less than three per week, unless the child is breast fed. At times chronic constipation (symptoms for at least 2 weeks) presents as recurrent abdominal pain, enuresis, nonstructural urinary tract infections, or fecal soiling. Children may complain of a feeling of incomplete elimination” (2). We suggest that any definition of constipation avoids establishing a minimum duration of symptoms for the characterization of constipation (8 or 12 weeks, as previously proposed (1, 3)), which may cause loss of precious time before intervention needed to prevent the development of undesirable complications in milder initial constipation. An alternative proposal would be to avoid the term “chronic constipation” using the term “functional constipation” instead. Finally, we would like to emphasize that we fully agree with the terminology and the concepts of organic fecal incontinence, functional fecal incontinence associated with constipation, functional nonretentive fecal incontinence, fecal impaction, and pelvic floor dyssynergia, proposed in Paris (3). Helga Verena Leoni Maffei, MD, PhD Full Professor of Pediatric Gastroenterology Medical School of Botucatu São Paulo State University (Universidade Estadual Paulista) São Paulo, Brazil Mauro Batista de Morais MD, PhD Associate Professor Division of Pediatric Gastroenterology Universidade Federal de São Paulo Escola Paulista de Medicina São Paulo, Brazil