Download Constipation, Encopresis and the Role of Dietary Fiber in

Constipation, encopresis, and
the role of dietary fiber in
management
Randy Rockney, M.D.
The Alpert Medical School of
Brown University
Hasbro Children’s Hospital
Providence, R.I.
Disclosure Statement
There are no financial conflicts to disclose.
Objectives
 Review
the epidemiology and
pathophysiology of constipation and
encopresis
 Discuss treatment options for constipation
and encopresis
 Discuss the role of dietary fiber in the
management of constipation and encopresis
Normal Frequency of Bowel
Movements
Age
Bowel
Bowel
Movements per Movements per
week
day
0-3 months
Breast milk
5-40
2.9
Formula
5-28
2.0
6-12 mos
5-28
1.8
1-3 years
4-21
1.4
>3 years
3-14
1.0
Definition of constipation
“A delay or difficulty in defecation for
more than 2 weeks, sufficient enough
to cause distress to the patient.”
North American Society for Pediatric
Gastroenterology and Nutrition (1999)
Constipation in 1st Century AD Rome
“With the little finger whose nail has first
been cut short one must for the
unhindered passing of the excrements
dilate the anus and divide the thin
membranous body which is often grown
around it.”
Soranus
Important points in history of patient
with constipation and encopresis I
 Age
of onset
 Frequency and consistency of stools
 Withholding behavior?
 Abdominal pain or distention
 Pain/bleeding with passage of stools
 Toilet training
 Previous and Current treatment--results
 Toilet use at school
Dread of school bathrooms
“A child who used to defecate each morning
at 11 AM at home may discover that there
are no doors in front of the toilets or that the
school lavatory is a well-publicized
amphitheater with a varied program of
humiliating scenarios.”
M.D. Levine, 1992
Important points in history of patient
with constipation and encopresis II
 Is
child aware of urge to defecate?
 Does child seem unaware of having
soiled?
 Does the family keep a broomstick (or
other peculiar object) in the bathroom for
emergencies?
 Does child hide soiled underwear?
 What time of day does soiling occur?
DSM-IV Criteria for Diagnosis
of Encopresis
 Involuntary
passage of feces into places
not appropriate for that purpose
 Must occur at least once a month for at
least 6 months
 Chronological and mental age of at least 4
years
 Physical disorders like aganglionic
megacolon must be ruled out
Epidemiology of Constipation
and Encopresis

Prevalence: among 7-8 year old children2.3% of boys, 1.3% of girls; among 10-12 year
old children-1.3% of boys, 0.3% of girls
 Male: Female 4-6:1
 3% of pediatric outpatient visits
 25% of pediatric gastroenterology visits
 50-60% secondary
 No study of natural history
Other conditions to think about with
constipation/encopresis






Anterior displacement of the anus, anal stenosis,
pelvic mass (sacral teratoma)
Hypothyroidism, hypercalcemia, hypokalemia,
DM, CF
Spinal cord abnormalities, e.g., tethered cord,
spinal cord trauma or tumor
Drugs: opiates, phenobarb, antacids,
antihypertensives, anticholinergics,
antidepressants
Physical or sexual abuse
Hirschsprung’s Disease
Encopresis: First steps
Education
Demystification
Evaluation of the Rectal Examination as a
Screening Instrument for the Determination of Fecal
Retention
Rectal
Examination
Diagnosis of Retention by
Abdominal X-ray
Positive Negative
Total
Positive
39
7
46
Negative
5
5
10
44
12
56
Total
Positive Predictive Value 85; Negative Predictive Value 50
(Sensitivity 88.6; Specificity 41.6)
Rectal examination and children
“The rule in deciding whether to perform an anogenital
examination during acute care should be the pertinence
of the examination to the specific complaint. For
example, a health care provider would be remiss not to
perform a rectal examination in a child with encopresis,
but such a procedure would be inappropriate for a simple
sore-throat complaint.”
(AAP) Policy Statement-Protecting Children from Sexual Abuse
by Health Care Providers. Pediatrics 2011;128:407-426
Encopresis treatment-Step I:
“When in doubt, clean ‘em out.”

Davidson (1962): 2-4 enemas then high dose
mineral oil
 Levine (1976): Enema, suppository, laxative
cycle x 2 weeks
 Heyman (1991): Mineral oil-30 ml/yr of age/bid x
2-7 days up to 300 ml bid (“No enema therapy”)
 Ingebo, Heyman (1988): Polyethylene glycolelectrolyte solution (Golytely) 14-40ml/kg/hr until
clear
Clean out program for_________

Day 1: Enema
 Day 2: Dulcolax
suppository
 Day 3: Dulcolax tablet
 Day 4: Enema
 Day 5: Dulcolax
suppository
 Day 6: Dulcolax tablet
 Day 7: Enema

Day 8: Enema
 Day 9: Dulcolax
suppository
 Day 10: Dulcolax tablet
 Day 11: Enema
 Day 12: Dulcolax
suppository
 Day 13: Dulcolax tablet
 Day 14: Return to clinic
Maintenance regimen goals: regularity
before continence
 At
least one soft stool per day
 Ability to sense urge to defecate in
time to use the toilet
 Reduced or no soiling
 Eventual ability to do the above with
life style and diet changes only
Maintenance regimen I: Basics





Use of a laxative on a daily basis at a dose
sufficient to produce a daily soft stool
Reduce intake of milk (<16-24 oz/day) and other
dairy products
Drink water and juices (prune, pear, apple)
Eat a diet high in fiber: (age in years + 5)X2 grams
Sit on toilet for 10-15 minutes 2-3x/day
Osmotic laxatives
Laxative
Dosage
Side
Effects
Comments
Lactulose
1-3 ml/kg/day
Flatulence,
cramps
Synthetic
disaccharide
Sorbitol
1-3 ml/kg/day
Same
Barley malt
extract
2-10 ml/240ml milk
or juice
MgCitrate
MgHydroxide
1-3 ml/kg/day
Unpleasant
odor
Mg overdose
in infants
WARNINGS
A theoretical hazard may exist for patients being treated
with lactulose who may be required to undergo
electrocautery procedures during proctoscopy or
colonoscopy. Accumulation of H2 gas in significant
concentration in the presence of an electrical spark may
result in an explosive reaction. Although this
complication has not been reported with lactulose,
patients on lactulose therapy undergoing such
procedures should have a thorough bowel cleansing with
a non-fermentable solution. Insufflation of CO2 as an
additional safeguard may be pursued but is considered
to be a redundant measure.
Package Insert
Stimulant laxatives
Laxative
Dosage
Side Effects
Senna
<6 ½-1½ tsp/day
6-12 1-3 tsp/day
Melanosis coli,
hepatitis
Bisacodyl
0.5-1 suppository or Abdominal pain
1-3 tabs/dose
Miralax (Polyethylene Glycol 3350)
 Osmotic
laxative
 Non-toxic, highly soluble, minimally
absorbed
 Acceptable to kids if dissolved
 Safe for long-term use
 Parent and physician need to be flexible
re: dosing
Dietary Fiber: Insoluble material
derived from edible plants
Insoluble: cellulose, hemicellulose, lignin;
in skins or structural parts of fruits/vegetables
and whole grains with germ or outer bran not
removed (think brown rice, whole wheat bread)
Soluble: pectins, gums and mucilages in fruits and
vegetables and some grains (oats)
Fiber Rich Foods
Purported Health Benefits of
Dietary Fiber
Lower blood cholesterol
Increase satiety/decrease obesity
Reduce risk of diabetes
Prevention and management of diverticulosis
Protection against colon and breast cancer
Promotion of normal laxation
How does fiber help GI function?
Insoluble fiber:
Reduces transit time
Increases stool weight and frequency
Soluble fiber:
Absorbs water in small intestine increasing
stool size; provides fermentable substrate for
colonic bacteria (source of flatulence)
Table 1. Recommendations for
fiber intake during childhood
Organization
American Academy of Pediatrics
Recommended Daily Intake
0.5 gm/kilogram
Food & Drug Administration
12 gm/1000 calories
U.S. Department of Agriculture
12 gm/1000 calories
American Health Foundation
Age + 5 (grams)
Table 2. Trends in dietary fiber intake during
childhood
Age (Yr)
1977-1978
NFCS*
mean
1987-1988 NFCS
Intake (gm/day)
1994-1996
NHANES#
2007-2008
2-5
8.9
8.2
9.6
11.3 ♂
10.5 ♀
6-11
12.1
11.5
13.1
13.7 ♂
12.0 ♀
12-18 males
15.2
14.0
17.4
14.9
12-18 females
11.0
10.6
13.0
13.3
*National Food Consumption Survey
#National Health and Nutrition Examination survey
Table 3. Fiber containing foods for Children
Food
Amount
Grams of Fiber
Raisin bran cereal
1 cup
7
Whole wheat biscuit
cereal
1 cup
6
1 cup cooked
4
Whole wheat bread
1 slice
2
Bran muffin
1 small
2
1
1
Baked beans
½ cup
10
Cooked green peas
½ cup
4
Cooked broccoli
½ cup
2
Cooked carrots
½ cup
2
½ medium
2
Grains
Oatmeal
Fruit filled cereal bar
Vegetables
Baked potato
Table 3. Fiber containing foods for
Children (continued)
Food
Amount
Grams of Fiber
1 medium
3
Orange
1 small
2
Strawberries
½ cup
2
Raisins
¼ cup
2
Fruits
Apple with peel
Group Behavioral Treatment of Retentive
Encopresis
Investigated the efficacy of behavioral group treatment for children with
retentive encopresis who had previously failed medical management.
Eighteen children between the ages of 4 and 11 years and their parents
were seen in small treatment groups of 3 to 5 families over 6 sessions.
The sessions focused on education about retentive encopresis, and the
integration of behavioral parenting procedures with medical management.
Parents and children were taught to deliver an enema clean-out, increase
the children's dietary fiber, and appropriate toileting techniques. The
results indicated that children significantly increased their fiber
consumption by 40%, increased appropriate toileting by 116%, and
decreased their soiling accidents by 83% pre- to posttreatment. Further,
these treatment gains maintained or improved at the 6-month follow-up.
The results are discussed in terms of cost-effective interventions and the
interface between psychology and medicine in pediatric psychology.
J Pediatr Psychol 1990 Oct;15(5):659-71.
Mean Grams of Fiber per Day
30
Young Children
Older Children
25
Baseline
20
Fiber Interv.
Toileting Interv.
15
6 mo. Follow-up
10
5
0
Fig 1. Mean grams of fiber consumed per day for younger children, ages
3 to 6 years, and older children, ages 7 to 12 years, across the three
phases of treatment (n = 7, younger children; n = 11, older children) and 6month follow-up (n = 5, younger children; n = 9, older children).
Mean # of Soiling Incidents and
Appropriate Bowel Movements per Week
Baseline
Fiber
Toileting
6 Mo. Followup
8
7
6
5
4
3
Soil
Appropriate
2
1
0
Fig 2. Mean number of soiling incidents and appropriate bowel
movements per week for all subjects across the three phases
of treatment (n = 18) and 6-month follow-up (n = 14).
Probiotics and constipation
 “Dysbiosis”
as possible cause of
constipation
 Probiotics like Bifidobacterium lactis DN173010 lowers colonic pH
 Lower pH enhances peristalsis
 Two RCTs (adults w/IBS and women)
showed increased stool frequency
Stool frequency per week
5.0
4.2 4.2
4.5
4.4
4.0
4.0
3.9
3.0
Placebo
2.0
Probiotics
1.6
1.3
1.0
0.0
Week 0
Week 1
Week 2
Week 3
Fig 3. Change in stool frequency from baseline to after 3 weeks
(P = .35) and overall test of stool frequency during treatment (P = .51)
Use of play with clay to treat children with
intractable encopresis
We used play with modeling clay to treat six children, aged 4 to 12 years,
with a history of intractable constipation with encopresis for a mean of 5.4
(2 to 8) years, refractory to treatment; biofeedback therapy had not been
tried. Clay was chosen because, as a brown, messy material, it was a
metaphor for feces and could let the child express either his disgust
or aggressivity, or let him build symbolic structures. No interpretation
was made during treatment. Four children had no symptoms during 2
months of therapy and no relapse during 1 year of follow-up, one child
improved significantly, and one child failed to respond but withdrew from
treatment after only three sessions. Modeling clay may be a cheap and
effective treatment modality for refractory constipation with encopresis.
J Pediatr.1993 Mar;122(3):483-8
Fig. 3. "Production" by patient 3. Top, Opus 1. Chronology is from right to left.
Last specimen does not have the form of a scybalum but looks like a formed
stool. Middle, Opus 2. "The toboggan." Bottom, Opus 3. "The story of my life."
J Pediatr.1993 Mar;122(3):486
Fig. 1. Opus 1 by patient 1. Child growing up in a
tub.
J Pediatr. 1993 Mar;122(3):485
Hasbro Partial Hospital
Program
A program for
school age children
with both medical
and psychological
needs
www.study.ucanpooptoo.co
m
“In appreciating the tragedy of encopresis, one
must conceptualize a human condition in which a
child is, shamed, or blamed (by himself and others)
for something he did not cause and over which he
has had little, if any, actual control.”
M.D. Levine