Preliminary Definition of Hospital-Acquired Constipation Among Critically Ill Children

Introduction: Pediatric functional constipation is a common chronic condition with a broadly accepted definition (i.e., Rome IV). Yet, among critically ill children Rome IV criteria are largely not applicable limiting the ability to estimate hospital-acquired constipation prevalence, identify context-specific risk factors, and evaluate prophylactic and treatment regimens. We aim to derive a preliminary consensus, expert definition for hospital-acquired constipation for critically ill children.


Methods: We performed a prospective, modified Delphi study from May - August 2025 conducted via electronic questionnaires at a quaternary pediatric referral center to gather anonymous expert feedback to define hospital-acquired constipation criteria for critically ill children. Refinement processes assessing levels of agreement (using >75% thresholds for consensus on parametric Likert scales) for unique criterion, applicable populations, and contextual covariates were used to generate a preliminary definition. The invited respondent panel included attending specialists in pediatric critical care medicine, gastroenterology, cardiac intensive care medicine, and general surgery.


Results: Two rounds of questionnaires were conducted with 23 and 20 respondents, respectively (response rates: 55% and 48%, respectively). Respondents included 67% intensivists, 9% general surgeons, and 21% gastroenterologists with 74.9% reporting >10 years’ attending experience. Upon refinement, major criteria to independently diagnose hospital-acquired constipation were: stooling dependent on (1) manual evacuation or (2) a chronic bowel regimen; and (3) fecal impaction by digital rectal examination. Minor criteria to define hospital-acquired constipation if present with ≥1 additional criteria were: (1) Bristol 1 or 2 stool consistency; (2) straining, dyschezia, or a sensation of incomplete evacuation or obstruction; (3) excess fecal load on abdominal imaging; and (4) the time between stooling events ≥72 hours for those 2 – 18 years of age and ≥96 hours for those 0 to 2 years of age.


Conclusions: We generated a preliminary, consensus, expert definition for hospital-acquired constipation for critically ill children that after further refinement and validation could be applied in epidemiologic and interventional research.