DEFECATION PATTERN DEFECATION PATTERN IN CHILDHOODIN CHILDHOOD

DEFECATION PATTERN DEFECATION PATTERN IN CHILDHOODIN CHILDHOOD

A normal recto-anal inhibitory reflexes only in newborn after 26 A normal recto-anal inhibitory reflexes only in newborn after 26 weeks of gestationweeks of gestation

Voluntary bowel control is achieved around 18 months of ageVoluntary bowel control is achieved around 18 months of age

The age at which complete control is attained is very variableThe age at which complete control is attained is very variable

• Many cultures have different age limitsMany cultures have different age limits• North America and Europe: age of 2-3 yearsNorth America and Europe: age of 2-3 years• Indonesia ?Indonesia ?

Below the age of six, the child become fully responsible for Below the age of six, the child become fully responsible for defecating in the accepted placedefecating in the accepted place

Voluntary bowel controlVoluntary bowel controlVoluntary bowel controlVoluntary bowel control

Breast fed infants had more bowel movement with Breast fed infants had more bowel movement with a greater range in number,a greater range in number, but but by by 16 weeks16 weeks (introduce solid food), no difference in stool freq.(introduce solid food), no difference in stool freq.

The increase in frequency of stool is related to the The increase in frequency of stool is related to the volume of milk ingestedvolume of milk ingested Unfed infants had a defecation rate of 1 stool per day.Unfed infants had a defecation rate of 1 stool per day. For each 50 ml/kg increase in volume milk showed the For each 50 ml/kg increase in volume milk showed the

further increase of 1 stool passed per dayfurther increase of 1 stool passed per day

Stool frequency ~ milk intakeStool frequency ~ milk intakeStool frequency ~ milk intakeStool frequency ~ milk intake

Stool frequency ~ ageStool frequency ~ ageStool frequency ~ ageStool frequency ~ age

A decline in the frequency of defecation with A decline in the frequency of defecation with ageage

• During the 1During the 1stst week of life: 1-9 stools/day week of life: 1-9 stools/day

• 22ndnd – 20 – 20thth week of life: 1-7 stools/day week of life: 1-7 stools/day

• 60-80% of 1-4 years children: 1 or 2 stools.day 60-80% of 1-4 years children: 1 or 2 stools.day

• Only 30% of the children opened their bowels Only 30% of the children opened their bowels less than 1 a dayless than 1 a day

Weaver LT et al, Arch Dis Child 1994;59Weaver LT et al, Arch Dis Child 1994;59

Fontana M et al, Act Pediattr Scand 1989Fontana M et al, Act Pediattr Scand 1989

Countries Bowel movement

USA

France

England

ThailandThailand

1 day 1.5 x/day1 day 1.5 x/day

5 day 4.4 x/day5 day 4.4 x/day

0-3 months 2.0-2.9 x/day0-3 months 2.0-2.9 x/day

6-12 month 1.8 x/day6-12 month 1.8 x/day

1-3 years 1-2 x/day1-3 years 1-2 x/day

Neonatal 3.3 x/dayNeonatal 3.3 x/day

4-6 years 1 x/day4-6 years 1 x/day

Stool frequency Stool frequency Stool frequency Stool frequency

Baker SS, 1999; Osatakul,1995

Frequency of defecationFrequency of defecationinfants 0-4 months of ageinfants 0-4 months of ageFrequency of defecationFrequency of defecation

infants 0-4 months of ageinfants 0-4 months of age

0

1

2

3

4

5

mo 1 mo 2 mo 3 mo 4

Edi S, Hegar B, Firmansyah A, 2003

Consistency of stoolConsistency of stoolConsistency of stoolConsistency of stool

Normal value for weight of stool output vary widely as Normal value for weight of stool output vary widely as consequence of dietary difference, consequence of dietary difference,

variation occurs even within individual subjects on a fixed variation occurs even within individual subjects on a fixed caloric and fibre intakecaloric and fibre intake

The inverse relation between stool weight and transit The inverse relation between stool weight and transit timetime

Diet high in fibre produced large stools more often Diet high in fibre produced large stools more often compare to those on a low-fibre diet who passed small compare to those on a low-fibre diet who passed small stools less frequentlystools less frequently

Reynold JC et al, 1987Reynold JC et al, 1987Tucker DM et al, Gastroenterology 1991Tucker DM et al, Gastroenterology 1991

0

10

20

30

40

50

60

70

80

90

100

0-4 day 5-14 day 15-113 114-120

soft

watery

Fecal consistencyFecal consistencyinfants 0-4 months of ageinfants 0-4 months of age

Fecal consistencyFecal consistencyinfants 0-4 months of ageinfants 0-4 months of age

Edi S, Hegar B, Firmansyah A, 2003

0

10

20

30

40

50

60

70

80

90

100

day 1 day 2 day 3 day 4 day 5-14 day15-10

Black

yelow

green

Colour of the fecalColour of the fecalinfants 0-4 months of ageinfants 0-4 months of age

Colour of the fecalColour of the fecalinfants 0-4 months of ageinfants 0-4 months of age

Edi S, Hegar B, Firmansyah A, 2003

CONSTIPATIONCONSTIPATION

ENCOPRESISENCOPRESIS

CONSTIPATIONCONSTIPATION

ENCOPRESISENCOPRESIS

ConstipationConstipation

Children Children << 4 years 4 years

• < 3 bowel movement per week< 3 bowel movement per week oror• painful bowel movementpainful bowel movement oror• rectal impaction rectal impaction oror• abdominal fecal mass on physical examination abdominal fecal mass on physical examination oror• all fourall four

Loening-Beucke V, Constipation in early childhood, Gut 1993;34:1400-4Loening-Beucke V, Constipation in early childhood, Gut 1993;34:1400-4

ConstipationConstipation

Children > 5 yearsChildren > 5 years (at least 2 of the following criteria) (at least 2 of the following criteria)

• Two or fewer bowel movement per week without laxativesTwo or fewer bowel movement per week without laxatives

• Two or more soiling/encopresis episodes per weekTwo or more soiling/encopresis episodes per week

• Periodic passage of very large amount of stools once every Periodic passage of very large amount of stools once every

7-30 days7-30 days

• a palpable abdominal or rectal mass on physical examinationa palpable abdominal or rectal mass on physical examination

Benninga MA, Thesis 1994Benninga MA, Thesis 1994

Constipation in Constipation in infants and preschool childreninfants and preschool children

5-10% (16% < 24 months) children had constipation 5-10% (16% < 24 months) children had constipation Constipation and subsequent fecal retention often begin Constipation and subsequent fecal retention often begin

soon after a child has experienced a painful evacuationsoon after a child has experienced a painful evacuation

Chronic constipation most often follows an inadequately Chronic constipation most often follows an inadequately managed acute problemmanaged acute problem

Infants: tend to extend the body, contract the anal and Infants: tend to extend the body, contract the anal and gluteal musclesgluteal muscles

Toddlers : rise on their toe, hold their legs and buttocks Toddlers : rise on their toe, hold their legs and buttocks stifflystiffly

Youssef Nader N, J of Clinical Gastroenterology 2001;33:199-205Rudolph CD, 1998

Constipation in school age childrenConstipation in school age childrenConstipation in school age childrenConstipation in school age children

The child is brought to medical attention because of The child is brought to medical attention because of encopresis (often of many years duration) or abdominal encopresis (often of many years duration) or abdominal painpain

EncopresisEncopresis• 2.8% in the age of 4 year 2.8% in the age of 4 year • 2.2% in the age of 5-6 years 2.2% in the age of 5-6 years • 1.5-19% in the age of 6-11 years 1.5-19% in the age of 6-11 years • 15% in obese children15% in obese children

Fishman L et al, J Pediatr 2004;145;253-4 Fishman L et al, J Pediatr 2004;145;253-4

Loening-Beucke V, Pediatric Clinnic of North America 1996;43:279-82Loening-Beucke V, Pediatric Clinnic of North America 1996;43:279-82

0

5

10

15

20

25

30

Jan March May Jul Sept Nov total

Constipation in childrenConstipation in childrenDivisi of Gastroenterology IKA-RSCM 2003Divisi of Gastroenterology IKA-RSCM 2003

Constipation in childrenConstipation in childrenDivisi of Gastroenterology IKA-RSCM 2003Divisi of Gastroenterology IKA-RSCM 2003

EncopresisEncopresis

The voluntary or involuntary passage of The voluntary or involuntary passage of a normal bowel movementa normal bowel movement

- - in the underwear (or other unorthodox in the underwear (or other unorthodox locations) locations) - after the age of four - after the age of four

- occurring on a regular basis without any organic - occurring on a regular basis without any organic causecause

Retentive encopresisRetentive encopresisFecal incontinence in children with clear evidence Fecal incontinence in children with clear evidence of constipationof constipation

Loening-Beucke V, Pediatric Clinnic of North America 1996;43:279-82 Loening-Beucke V, Pediatric Clinnic of North America 1996;43:279-82

EncopresisEncopresisEncopresisEncopresis

• Parents often assume that encopresis is caused by Parents often assume that encopresis is caused by the reluctance of the child to use the toiletthe reluctance of the child to use the toilet

• The frequency: once or many times a day or The frequency: once or many times a day or intermittentintermittent

• A periode free of soiling after a large bowel movementA periode free of soiling after a large bowel movement• Soiling resumes after several days of stool retentionSoiling resumes after several days of stool retention

• Encopresis is a complication of long standing Encopresis is a complication of long standing constipationconstipation

Loening-Beucke V, Pediatric Clinnic of North America 1996;43:279-82

Defecation pattern in children is a wide range and is a wide range and individual variationindividual variation

Constipation is common in children and it is estimated 5-16% of pediatric patients have constipation and/or encopresis

ConclusionConclusionConclusionConclusion

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