Sir,

I read the recent report by Kokke et al. [1] with great interest. Kokke et al. [1]. concluded that “The Starreveld scoring method to assess faecal loading on a plain abdominal radiograph is of limited value in the diagnosis of childhood constipation”. I would like to share ideas on this work. First, there are several causes of constipation (functional nonretentive faecal incontinence, or functional or organic constipation) that might lead to differences in the scoring result. To give clear information on the usefulness of a scoring system, the study should completely detail and group the subjects based on causes of constipation that can be seen in a previous referenced publication [2]. Second, there might be some bias in the design of this work. It is not common to use four observers as in this work. In general, three observers are used in this kind of assessment [2]. In addition, it is required to test the basic abilities of each observer before starting the study. Differences in experience are reported to result in different resultant scoring in this kind of assessment [3]. Third, I have a question: If the cut-off value is adjusted to different age-specific paediatric groups, will the scoring system be acceptable or not?