GUIDELINE PARA INCONTINÊNCIA FECAL..

A Guideline for Children with Functional Fecal Incontinence
A.M.W. Bulk-Bunschoten*, M.A. Benninga**, C.M.F. Kneepkens***, M.F. van der Wal+, R.A. Hirasing* * Department of Public and Occupational Health and EMGO Institute VU University Medical Centre, Amsterdam** Department of Paediatrics, Academic Medical Centre, Amsterdam***Department of Pediatric Gastroenterology, VU University Medical Centre, Amsterdam+Cluster of Epidemiology and Health Promotion, Municipal Health Service, Amsterdam
Address for Correspondence: A.M.W. Bulk-Bunschoten, VUmc, EMGO instituut,Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands. Email: amw.bulk@vumc.nl AbstractFecal incontinence may be due to organic diseases or functional disorders. In the majority of cases, fecal incontinence is the result of constipation. Requests for help are often delayed. If these children do not receive counselling or treatment in good time, there is a risk of persistent constipation and associated psychological harm. A guideline is therefore needed to identify earlier, to counsel and to treat these children. This prevents, in all probability, secondary psychological damage. This paper sets out a phased plan that is appropriate for use in the primary health care and by pediatricians. The phased plan consists of keeping a diary, completing a medical history checklist, physical examination, toilet training, exercise and diet recommendations and the use of laxatives. Keywords: fecal incontinence, children, guideline
Introduction
There are several guidelines in the literature for nocturnal enuresis.1 However, no guidelines are available to identify council and treat children with fecal incontinence, neither for use in the primary health care nor for use by paediatricians. A group of experts in the field of defecation disorders in childhood suggested that the term fecal incontinence should be adopted in place of the terms encopresis and soiling, and offered the following definition: passage of stools in an inappropriate place.2 In different cultural environments, such as in the US, Australia or England encopresis and soiling have been used with different meanings. Therefore it was felt that the term fecal incontinence should be used whenever possible to avoid confusion or misunderstanding.2 It may be due to organic diseases (resulting from neurological damage or anal sphincter abnormalities), or functional disorders, (constipation-associated fecal incontinence and non-retentive fecal incontinence). The number of children with fecal incontinence is increasing both globally and nationally.3-5 Children can be considered to have reached fecal continence when, after feeling the urge to defecate, they are able to control their bowel movement until reaching a suitable place where they defecate at their own volition or at the request of others. Parental praise for the acquisition of this skill gives them self-confidence and a sense of self-respect. On the other hand, if parents are ashamed of any difficulty in this area, there is a considerable risk that they increase pressure on their child, thereby exacerbating and prolonging the incontinence problem.6 Children who do not reach fecal continence before visiting a primary school may be bullied, and they may become isolated as a result. Usually, parents only decide to visit the primary health care at a late stage.6 It is not advisable to wait until children achieve continence spontaneously. A timely and generally accepted, approach is needed. In order to establish a systematic approach to fecal incontinence, we established a multidisciplinary working group. By this group a guideline was drafted with a number of recommendations relating to medical history, physical examination, required supplementary examination and treatment. The guideline provides a basis for identifying children with fecal incontinence and for counselling and treatment or to refer to a paediatrician for treatment.
Prevalence
Most children achieve fecal continence between 2 and 3 years of age. Large-scale surveys in the Netherlands and Switzerland have shown that over 90% of children achieve bladder and bowel control before their third birthday.7,8 It is striking that girls are continent in both respects at an earlier age. As at present this difference is not explained. Development of bladder and bowel control is largely a maturational process which can not be hastened by early onset or high intensity of toilet training.9 Withholding behaviour and constipation have a negative effect on achieving continence.10-12 Table 1 lists the factors associated with fecal incontinence.
Table 1. Factors associated with fecal incontinence
ConstipationToilet trainingFamily problems Psychiatric problems (e.g. child schizophrenia)Mental retardation (e.g. Down syndrome)Neurological disease (e.g. meningomyelocele)Anatomical deviations (e.g. perforated anus and Hirsprung’s disease)Coercive toilet training can result in children acquiring an aversion to defecation which sometimes can result in withholding behaviour with severe fecal impaction in the rectum. The large, hard stools are often only evacuated once a week on the toilet in a difficult and painful process. A vicious circle is established that can only be broken using oral, and sometimes rectal, laxatives. In 60-90% of children, constipation is accompanied by fecal incontinence.13 Fecal incontinence becomes less prevalent with age and is rare in adults.14 However, a recent study found that 20-30% of children with constipation and fecal incontinence continue to have problems after the age of 18.15,16 The reported prevalence for fecal incontinence is 1–3 % in children of 4 years of age and older.6 A study of 1583 schoolchildren in the area of West-Friesland in the Northern of The Netherlands showed that 2.2% of children experienced fecal incontinence at the age of five (3.1% of boys and 0.9% of girls). In 6-year-olds, this percentage fell to 1.1.6 In a more recent study (2000-2003) of school children in Amsterdam aged between five and six years and between eleven and twelve years, the prevalence was 4.1% (4.7% of boys and 2.4% of girls) and 1.6%, respectively.6 The prevalence in the younger group was lower for Moroccan and Turkish children (2.3% and 2.2% respectively) than for Dutch children (3.5%). Identification of fecal incontinenceTasks of the primary health care are to identify children with continence difficulties in good time and to provide counselling and treatment, or to refer children for counselling and treatment. In The Netherlands incontinence in children is traced during individual consultations. The parents are asked whether their child has had stools or traces of stools in their underwear in the last month. If this is the case, the medical history checklist is completed (table 2).
Table 2. Medical history checklist 1 *
Meconium passage more than 24 hours after birth
yes
no
Constipation before the age of 3 months
yes
no
Fecal incontinence without symptoms of constipation
yes
no
Nocturnal loss of faeces
yes
no
The child smears faeces
yes
no* If the answer to one or more questions is yes, questioning continues with medical history checklist II and a physical examination takes place. If the answer to one or more questions in the medical history checklist is positive, more questions are asked. Depending on the answers and the physical examination (table 3), the child is referred to a paediatrician.
Table 3. Specific physical examination
General impressionAssessment of increase in length and weightPalpation of abdomen: scybala present? Inspection of anus: fissures present?Anal dilatation? Nocturnal fecal incontinence, anal fissures (in children over the age of 2 years) and anal dilatation, as well as children smearing with stools, are alarm symptoms. The nocturnal leakage of stools is significantly correlated to fecaloma and a total colonic transit time of more than 100 hours (normal < 62 hours).17 Fissures and anal dilatation may indicate sexual abuse. Anal dilatation is also found in children with severe fecal impaction. In exceptional cases, a neurological cause may underlie anal dilatation. If an alarm symptom is found, the child will be referred to a paediatrician. In case of indications of sexual abuse, a child abuse protocol will go into operation as well. If the medical history and physical examination do not suggest abnormalities or functional non-retentive fecal soiling, medical history checklist II (table 4) is completed in order to establish possible approaches for recommendations. The completed list serves as a reference point. Psychosocial, behavioural and emotional problems, abuse and learning and educational difficulties are checked using standardized questionnaires.18
Table 4. Medical history checklist 2
1. When was bladder and bowel control acquired? Bladder control? day……night…… Bowel control? day……night……2. Was your child toilet trained for more than six months? yes…..no….. if so, when……3. Are there any identifiable events after which control was lost? yes…..no…..….if so, which4.* How often did your child have fecal incontinence in the last month?
1-4 times a month
2-3 times a week
4-6 times a week
every day
several times a day5.* At what time of the day did your child have fecal incontinence?
morning
after school
at no particular time during the day
day and night 6.* Describe your child's stools.
Always loose and in small quantities
Normal and in normal quantities
Hard and in large quantities7.* Does your child have pain during defecation? yes…..no….. 8.* Does your child suffer from stomach-ache at least 4 times a week? yes………no……… 9.* Does your child feel the urge to defecate? yes………no……. Does your child go to the toilet of its own accord? yes…..no….. Do you have to remind your child to go to the toilet? yes….no….10.* Your child and eating Does your child have a good appetite? yes……no….. Does your child eat fruit, vegetables and bread every day? yes…..no….. Did your child have a food allergy as an infant? yes…..no……11. Does your child take medication? yes…..no…..…. if so, which medication?12. How do people respond to fecal incontinence? In the family At school13. What have you tried to resolve the problem? TreatmentMost children with fecal incontinence, if medical history and physical examination are unremarkable, can be treated and counselled within the primary health care. Sometimes lengthy counselling or treatment is needed. 19-21 Children need family support during the treatment. The problem can be alleviated for families by explaining to parents about preventing the problem and by explaining that their children are not doing it just to annoy them. This explanation precedes the treatment. Without the cooperation of parents, there is no point in using the guideline: it will be more likely to have an adverse effect. The successive components of the guideline are (table 5):
Table 5. Guideline
Phase 1duration: 3weeks
Diagnosis of fecal incontinence on the basis of- Completion of medical history checklists - Physical examination
Explanation and educationIntroduction of bowel diary
Phase 2duration: 4 weeks
Simple recommendations- Toilet training sitting on toilet at set times - More exercise every day-Recommendations about eating patterns
Use bowel diary and keep records about trainingChild's drawing bookActivity bookNormal eating patterns
Phase 3duration: 1 year
Laxatives- Cleaning phase - Maintenance phase- Run-down phase
Use bowel diary, keep records about training and use drawing bookChild goes to toilet itself Diagnosis of fecal incontinenceA bowel diary is used every day for two weeks to establish defecation and fecal incontinence frequency precisely. Simple recommendationsOnce the defecation and fecal incontinence symptoms have been objectively established using the diary, the child and the parents are advised to start toilet training: three times a day (for at least five and no more than ten minutes), approximately 15 minutes after meals. The best position for defecation is obtained by keeping both feet on the floor or by using a footstool in front of the toilet so that the ankles, knees and hips are in the flexion position (90o). Even if the child does not feel the urge to do so, it may push actively. If defecation is successful, the child is lavishly praised. The parents keep a diary for a month to record defecation and the frequency of toilet training. Additionally, children are advised to exercise for at least one hour a day. The time spent watching television and playing computer games must not exceed the time during which the child is active (cycling, walking and playing outside). The diary is also used to keep a record of this. Healthy, fibre-rich food (brown bread, fruit and vegetables) combined with an adequate intake of liquids (1/2 to 1 litre of liquids a day) is strongly advised. Children should not skip meals. The care officer gets in touch again two months after the symptoms of constipation have disappeared to assure that the children did not relapse in the old pattern. Thirty percent of children relapse within that time.19 Use of laxativesIf straightforward recommendations fail to have the desired effect on constipation and fecal incontinence within two months, laxatives are used. For the vast majority of children, oral laxatives will suffice (table 6). Enemas and suppositories are only appropriate when there is acute, severe abdominal pain requiring immediate relief and when a digital examination indicates that there is a large impacted fecal mass. A high dose of laxative (preferably polyethylene glycol or lactulose) is required initially in order to render the stools soft enough to make retention and resistance no longer successful (table 6).22-26 Abdominal cramps and flatulence may be temporary side-effects, and this should be explained to the child and parents beforehand. Polyethylene glycol and lactulose are considered safe, also on the long term. If there is no improvement within 6 weeks or if the symptoms worsen, referral follows to a paediatrician with special experience in dealing with fecal incontinence. If there is an improvement, the maintenance phase begins, usually lasting six months. During this phase, laxatives are used to ensure frequency and to keep stools soft. After approximately four months, the laxative dose can be reduced while the training programme is continued. A record is kept during this phase in the parental diary about whether children go to the toilet themselves or have to be reminded. Once the defecation frequency normalised and fecal incontinence disappeared, the run-down phase starts. During this phase, toilet training is gradually cut back. The child must go to the toilet of its own accord. It no longer receives medication. Constipation is a chronic problem in many children, and occasional use of laxatives will be required in certain situations (for example on holiday). During this phase, 30% of the children suffer a relapse (usually temporarily). Sixty percent of the children are symptom-free after one year.15 If the underlying problem – constipation or psychosocial – is so stubborn as to preclude enduringly successful treatment, referral to a tertiary centre will be necessary.
Table 6 . Laxatives for fecal incontinence20
Laxative
Dose
Side-effects in children
Use in children
Polyethylene glycol*
0.5-1g/kg per day
Loose stools, sometimes bad taste (PEG + additional electrolytes)
+
Lactulose*Lactitol*
1-3 ml/kg 1-2 times a day
Abdominal pain, flatulence
+
Metamucil
6-12 years of age: 1-2 times a day 1 sachet
Unpleasant taste
-
Bisacodyl
5-10 mg every other day (oral)5 mg every other day (rectal)
Abdominal cramps, abdominal pain, diarrhoea
+/-
Magnesium oxide
200-500 mg per day
Hypermagnesaemia: due to concurrent renal failure
-
Liquid paraffin
1-2 ml/kg per day
Sometimes bad taste, anal leakage, aspiration pneumonia (<12 months dysphagia)
-
Sodium docusate+ sorbitol enema**
<> 6 years of age: 120 ml
Abdominal cramps

Sodium bisphosphate enema ‘Fleet’**
>20 kg: 120 ml
In case of renal problems: hyperphosphataemia, other electrolyte disturbances. Idiosyncratic reaction

Sodium laurylsulfoacetate enema ‘Microlax’** Infants
< 10 kg: 5 ml
Abdominal cramps, anal irritation
*freely available in The Netherlands**only in acute situations
Prevention
Functional constipation starts in 50% of children as early as the first six months of life.19 Previous studies have shown that early identification and treatment of the disorder improves the long-term prognosis.27,28 This means that it is very important for constipation and fecal incontinence to be identified and treated in time. During every consultation of a primary health check, questions should be asked about toilet habits. If a child suffers from constipation, recommendations should be given about diet and exercise (baby bouncers restrict babies' movements!). Where necessary, polyethylene glycol or lactulose should be given daily in regular time. Frequent switching between different brands of formula is not advisable. There is a lack of good randomised studies of the effect on defecation frequency and consistency after carob bean gum or oligosaccharides have been added to formula. Constipation is never a reason to stop breastfeeding, especially not at the age of 1-3 months, the period when infrequent defecation is common and normal in breastfed infants. The switch to formula may even exacerbate the problem. There is no reason to introduce extra liquids to the diet of an infant receiving enough liquids and properly prepared formula. Adding oil to the food is also inadvisable since more than 90% of the fats are absorbed in the small intestine. Excessive amounts of extra oil could result in aspiration and malabsorption of fat-soluble vitamins. Soap suppositories and the use of a rectal thermometer to induce defecation are also inappropriate, since they may result in mucosal damage.
Conclusion
Children with fecal incontinence are traced using a medical history checklist and physical examination. Where appropriate, referral to a paediatrician is the next step. If the guideline is used, it will quickly become clear which children need extensive and ongoing treatment. Research is required to determine whether the guideline helps to trace and treat children with fecal incontinence earlier, to identify the long-term results and to determine whether it prevents secondary psychological damage.
Acknowledgements
We wish to thank the Maag Lever Darm Stichting for the grant that made the development of this guideline possible.
References
Fritz G, Rockney R, Bernet W, Arnold V, et al. Practice parameter for the assessment and treatment