Constipation, encopresis, and Constipation, encopresis, and the role of dietary fiber in the role of dietary fiber in

managementmanagement

Randy Rockney, M.D.Randy Rockney, M.D.

The Alpert Medical School of The Alpert Medical School of

Brown UniversityBrown University

Hasbro Children’s HospitalHasbro Children’s Hospital

Providence, R.I.Providence, R.I.

Disclosure StatementDisclosure Statement

There are no financial conflicts to disclose.There are no financial conflicts to disclose.

ObjectivesObjectives

Review the epidemiology and Review the epidemiology and pathophysiology of constipation and pathophysiology of constipation and encopresisencopresis

Discuss treatment options for constipation Discuss treatment options for constipation and encopresisand encopresis

Discuss the role of dietary fiber in the Discuss the role of dietary fiber in the management of constipation and encopresismanagement of constipation and encopresis

Normal Frequency of Bowel Normal Frequency of Bowel MovementsMovements

Age Bowel Movements per

week

Bowel Movements per

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 constipationDefinition 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 RomeConstipation 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 Important points in history of patient with constipation and encopresis Iwith constipation and encopresis I

Age of onsetAge of onset Frequency and consistency of stoolsFrequency and consistency of stools Withholding behavior?Withholding behavior? Abdominal pain or distentionAbdominal pain or distention Pain/bleeding with passage of stoolsPain/bleeding with passage of stools Toilet trainingToilet training Previous and Current treatment--resultsPrevious and Current treatment--results Toilet use at schoolToilet use at school

Dread of school bathroomsDread of school bathrooms

““A child who used to defecate each morning A child who used to defecate each morning at 11 AM at home may discover that there at 11 AM at home may discover that there are no doors in front of the toilets or that the are no doors in front of the toilets or that the school lavatory is a well-publicized school lavatory is a well-publicized amphitheater with a varied program of amphitheater with a varied program of humiliating scenarios.”humiliating scenarios.”

M.D. Levine, 1992M.D. Levine, 1992

Important points in history of patient Important points in history of patient with constipation and encopresis IIwith constipation and encopresis II

Is child aware of urge to defecate?Is child aware of urge to defecate? Does child seem unaware of having Does child seem unaware of having

soiled?soiled? Does the family keep a broomstick (or Does the family keep a broomstick (or

other peculiar object) in the bathroom for other peculiar object) in the bathroom for emergencies?emergencies?

Does child hide soiled underwear?Does child hide soiled underwear? What time of day does soiling occur?What time of day does soiling occur?

DSM-IV Criteria for Diagnosis DSM-IV Criteria for Diagnosis of Encopresisof Encopresis

Involuntary passage of feces into places Involuntary passage of feces into places not appropriate for that purposenot appropriate for that purpose

Must occur at least once a month for at Must occur at least once a month for at least 6 monthsleast 6 months

Chronological and mental age of at least 4 Chronological and mental age of at least 4 yearsyears

Physical disorders like aganglionic Physical disorders like aganglionic megacolon must be ruled outmegacolon must be ruled out

Epidemiology of Constipation Epidemiology of Constipation and Encopresisand Encopresis

Prevalence: among 7-8 year old children-Prevalence: among 7-8 year old children-2.3% of boys, 1.3% of girls; among 10-12 year 2.3% of boys, 1.3% of girls; among 10-12 year old children-1.3% of boys, 0.3% of girlsold children-1.3% of boys, 0.3% of girls

Male: Female 4-6:1Male: Female 4-6:1 3% of pediatric outpatient visits3% of pediatric outpatient visits 25% of pediatric gastroenterology visits25% of pediatric gastroenterology visits 50-60% secondary50-60% secondary No study of natural historyNo study of natural history

Other conditions to think about with Other conditions to think about with constipation/encopresisconstipation/encopresis

Anterior displacement of the anus, anal stenosis, Anterior displacement of the anus, anal stenosis, pelvic mass (sacral teratoma)pelvic mass (sacral teratoma)

Hypothyroidism, hypercalcemia, hypokalemia, DM, Hypothyroidism, hypercalcemia, hypokalemia, DM, CFCF

Spinal cord abnormalities, e.g., tethered cord, spinal Spinal cord abnormalities, e.g., tethered cord, spinal cord trauma or tumorcord trauma or tumor

Drugs: opiates, phenobarb, antacids, Drugs: opiates, phenobarb, antacids, antihypertensives, anticholinergics, antidepressantsantihypertensives, anticholinergics, antidepressants

Physical or sexual abusePhysical or sexual abuse Hirschsprung’s DiseaseHirschsprung’s Disease

Encopresis: First stepsEncopresis: First steps

Education

Demystification

Evaluation of the Rectal Examination as a Evaluation of the Rectal Examination as a Screening Instrument for the Determination of Fecal Screening Instrument for the Determination of Fecal

RetentionRetention

Diagnosis of Retention byAbdominal X-rayRectal

Examination Positive Negative Total

Positive 39 7 46

Negative 5 5 10

Total 44 12 56

Positive Predictive Value 85; Negative Predictive Value 50(Sensitivity 88.6; Specificity 41.6)

Rectal examination and childrenRectal examination and children

““The rule in deciding whether to perform an anogenital The rule in deciding whether to perform an anogenital examination during acute care should be the pertinence examination during acute care should be the pertinence of the examination to the specific complaint. For of the examination to the specific complaint. For example, a health care provider would be remiss not to example, a health care provider would be remiss not to perform a rectal examination in a child with encopresis, perform a rectal examination in a child with encopresis, but such a procedure would be inappropriate for a simple but such a procedure would be inappropriate for a simple sore-throat complaint.”sore-throat complaint.”

(AAP) Policy Statement-Protecting Children from Sexual Abuse

by Health Care Providers. Pediatrics 2011;128:407-426

Encopresis treatment-Step I: Encopresis treatment-Step I: “When in doubt, clean ‘em out.”“When in doubt, clean ‘em out.”

Davidson (1962): 2-4 enemas then high dose Davidson (1962): 2-4 enemas then high dose mineral oilmineral oil

Levine (1976): Enema, suppository, laxative Levine (1976): Enema, suppository, laxative cycle x 2 weekscycle x 2 weeks

Heyman (1991): Mineral oil-30 ml/yr of age/bid x Heyman (1991): Mineral oil-30 ml/yr of age/bid x 2-7 days up to 300 ml bid (“No enema therapy”)2-7 days up to 300 ml bid (“No enema therapy”)

Ingebo, Heyman (1988): Polyethylene glycol-Ingebo, Heyman (1988): Polyethylene glycol-electrolyte solution (Golytely) 14-40ml/kg/hr until electrolyte solution (Golytely) 14-40ml/kg/hr until clearclear

Clean out program for_________Clean out program for_________

Day 1: EnemaDay 1: Enema Day 2: Dulcolax Day 2: Dulcolax

suppositorysuppository Day 3: Dulcolax tabletDay 3: Dulcolax tablet Day 4: EnemaDay 4: Enema Day 5: Dulcolax Day 5: Dulcolax

suppositorysuppository Day 6: Dulcolax tabletDay 6: Dulcolax tablet Day 7: EnemaDay 7: Enema

Day 8: EnemaDay 8: Enema Day 9: Dulcolax Day 9: Dulcolax

suppositorysuppository Day 10: Dulcolax tabletDay 10: Dulcolax tablet Day 11: EnemaDay 11: Enema Day 12: Dulcolax Day 12: Dulcolax

suppositorysuppository Day 13: Dulcolax tabletDay 13: Dulcolax tablet Day 14: Return to clinicDay 14: Return to clinic

Maintenance regimen goals: regularity Maintenance regimen goals: regularity before continencebefore continence

At least one soft stool per dayAt least one soft stool per day Ability to sense urge to defecate in Ability to sense urge to defecate in

time to use the toilettime to use the toilet Reduced or no soilingReduced or no soiling Eventual ability to do the above with Eventual ability to do the above with

life style and diet changes onlylife style and diet changes only

Maintenance regimen I: BasicsMaintenance regimen I: Basics

Use of a laxative on a daily basis at a dose Use of a laxative on a daily basis at a dose sufficient to produce a daily soft stoolsufficient to produce a daily soft stool

Reduce intake of milk (<16-24 oz/day) and other Reduce intake of milk (<16-24 oz/day) and other dairy productsdairy products

Drink water and juices (prune, pear, apple)Drink water and juices (prune, pear, apple) Eat a diet high in fiber: (age in years + 5)X2 gramsEat a diet high in fiber: (age in years + 5)X2 grams Sit on toilet for 10-15 minutes 2-3x/daySit on toilet for 10-15 minutes 2-3x/day

Osmotic laxativesOsmotic laxatives

LaxativeLaxative DosageDosage Side Side EffectsEffects

CommentsComments

LactuloseLactulose 1-3 ml/kg/day1-3 ml/kg/day Flatulence, Flatulence, crampscramps

Synthetic Synthetic disaccharidedisaccharide

SorbitolSorbitol 1-3 ml/kg/day1-3 ml/kg/day SameSame

Barley malt Barley malt extractextract

2-10 ml/240ml milk 2-10 ml/240ml milk

or juiceor juice

Unpleasant Unpleasant odorodor

MgCitrate MgCitrate MgHydroxideMgHydroxide

1-3 ml/kg/day1-3 ml/kg/day Mg overdose Mg overdose

in infantsin infants

WARNINGSWARNINGSA theoretical hazard may exist for patients being treated A theoretical hazard may exist for patients being treated with lactulose who may be required to undergo with lactulose who may be required to undergo electrocautery procedures during proctoscopy or electrocautery procedures during proctoscopy or colonoscopy. colonoscopy. Accumulation of H2 gas in significant Accumulation of H2 gas in significant concentration in the presence of an electrical spark may concentration in the presence of an electrical spark may result in an explosive reaction.result in an explosive reaction. Although this Although this complication has not been reported with lactulose, complication has not been reported with lactulose, patients on lactulose therapy undergoing such patients on lactulose therapy undergoing such procedures should have a thorough bowel cleansing with procedures should have a thorough bowel cleansing with a non-fermentable solution. Insufflation of CO2 as an a non-fermentable solution. Insufflation of CO2 as an additional safeguard may be pursued but is considered additional safeguard may be pursued but is considered to be a redundant measure. to be a redundant measure.

Package InsertPackage Insert

Stimulant laxativesStimulant laxatives

LaxativeLaxative DosageDosage Side EffectsSide Effects

SennaSenna <6 ½-1½ tsp/day<6 ½-1½ tsp/day

6-12 1-3 tsp/day6-12 1-3 tsp/day

Melanosis coli, Melanosis coli, hepatitishepatitis

BisacodylBisacodyl 0.5-1 suppository or 0.5-1 suppository or 1-3 tabs/dose1-3 tabs/dose

Abdominal painAbdominal pain

Miralax Miralax (Polyethylene Glycol 3350)(Polyethylene Glycol 3350)

Osmotic laxativeOsmotic laxative Non-toxic, highly soluble, minimally Non-toxic, highly soluble, minimally

absorbedabsorbed Acceptable to kids if Acceptable to kids if dissolveddissolved Safe for long-term useSafe for long-term use Parent and physician need to be flexible Parent and physician need to be flexible

re: dosingre: dosing

Dietary Fiber: Insoluble material Dietary Fiber: Insoluble material derived from edible plantsderived from edible plants

Insoluble: cellulose, hemicellulose, lignin;in skins or structural parts of fruits/vegetablesand whole grains with germ or outer bran notremoved (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 timeIncreases 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 Table 1. Recommendations for fiber intake during childhoodfiber intake during childhood

OrganizationOrganization Recommended Daily IntakeRecommended Daily Intake

American Academy of PediatricsAmerican Academy of Pediatrics 0.5 gm/kilogram0.5 gm/kilogram

Food & Drug AdministrationFood & Drug Administration 12 gm/1000 calories12 gm/1000 calories

U.S. Department of AgricultureU.S. Department of Agriculture 12 gm/1000 calories12 gm/1000 calories

American Health FoundationAmerican Health Foundation Age + 5 (grams)Age + 5 (grams)

Table 2. Trends in dietary fiber intake during Table 2. Trends in dietary fiber intake during childhoodchildhood

Age (Yr)Age (Yr) 1977-1978 1977-1978 NFCS*NFCS*

meanmean

1987-1988 NFCS1987-1988 NFCS

Intake (gm/day)Intake (gm/day)

1994-1996 1994-1996

NHANESNHANES##

2007-20082007-2008

2-52-5 8.98.9 8.28.2 9.69.6 11.3 11.3 ♂♂

10.5 ♀10.5 ♀

6-116-11 12.112.1 11.511.5 13.113.1 13.7 13.7 ♂♂

12.0 12.0 ♀♀

12-18 males12-18 males 15.215.2 14.014.0 17.417.4 14.914.9

12-18 females12-18 females 11.011.0 10.610.6 13.013.0 13.313.3

*National Food Consumption Survey

#National Health and Nutrition Examination survey

Table 3. Fiber containing foods for ChildrenTable 3. Fiber containing foods for ChildrenFoodFood AmountAmount Grams of FiberGrams of Fiber

GrainsGrains

Raisin bran cerealRaisin bran cereal 1 cup1 cup 77

Whole wheat biscuit Whole wheat biscuit cerealcereal

1 cup1 cup 66

OatmealOatmeal 1 cup cooked1 cup cooked 44

Whole wheat breadWhole wheat bread 1 slice1 slice 22

Bran muffinBran muffin 1 small1 small 22

Fruit filled cereal barFruit filled cereal bar 11 11

VegetablesVegetables

Baked beansBaked beans ½ cup½ cup 1010

Cooked green peasCooked green peas ½ cup½ cup 44

Cooked broccoliCooked broccoli ½ cup½ cup 22

Cooked carrotsCooked carrots ½ cup½ cup 22

Baked potatoBaked potato ½ medium½ medium 22

Table 3. Fiber containing foods for Table 3. Fiber containing foods for Children (continued)Children (continued)

FoodFood AmountAmount Grams of FiberGrams of Fiber

FruitsFruits

Apple with peelApple with peel 1 medium1 medium 33

OrangeOrange 1 small1 small 22

StrawberriesStrawberries ½ cup½ cup 22

RaisinsRaisins ¼ cup¼ cup 22

Group Behavioral Treatment of Retentive Group Behavioral Treatment of Retentive EncopresisEncopresis

J Pediatr Psychol 1990 Oct;15(5):659-71.

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.

0

5

10

15

20

25

30

Baseline

Fiber Interv.

Toileting Interv.

6 mo. Follow-up

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 6-month follow-up (n = 5, younger children; n = 9, older children).

Young Children Older ChildrenM

ea

n G

ram

s o

f F

ibe

r p

er

Day

0

1

2

3

4

5

6

7

8

Soil

Appropriate

Me

an

# o

f S

oili

ng

Inc

ide

nts

an

d

Ap

pro

pri

ate

Bo

we

l Mo

ve

me

nts

pe

r W

eek

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).

Baseline Fiber Toileting 6 Mo. Follow-up

Probiotics and constipationProbiotics and constipation

““Dysbiosis” as possible cause of Dysbiosis” as possible cause of constipationconstipation

Probiotics like Bifidobacterium lactis DN-Probiotics like Bifidobacterium lactis DN-173010 lowers colonic pH173010 lowers colonic pH

Lower pH enhances peristalsisLower pH enhances peristalsis Two RCTs (adults w/IBS and women) Two RCTs (adults w/IBS and women)

showed increased stool frequencyshowed increased stool frequency

1.3

4.24.0 3.9

1.6

4.24.4 4.5

0.0

1.0

2.0

3.0

4.0

5.0

Week 0 Week 1 Week 2 Week 3

Placebo

Probiotics

Sto

ol f

requ

ency

per

wee

k

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 Use of play with clay to treat children with intractable encopresisintractable 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 Hasbro Partial Hospital ProgramProgram

A program for A program for school age children school age children with both medical and with both medical and psychological needspsychological needs

www.study.ucanpooptoo.com

“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