DEFECATION PATTERN IN CHILDHOOD

Voluntary bowel control

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

Voluntary bowel control is achieved around 18 months of age The age at which complete control is attained is very variable

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

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

Stool frequency ~ milk intake

Breast fed infants had more bowel movement with a greater range in number, but by 16 weeks (introduce solid food), no difference in stool freq. The increase in frequency of stool is related to the volume of milk ingested

Unfed infants had a defecation rate of 1 stool per day. For each 50 ml/kg increase in volume milk showed the further increase of 1 stool passed per day

Stool frequency ~ age

A decline in the frequency of defecation with age

During the 1st week of life: 1-9 stools/day 2nd 20th week of life: 1-7 stools/day 60-80% of 1-4 years children: 1 or 2 stools.day Only 30% of the children opened their bowels
less than 1 a day

Weaver LT et al, Arch Dis Child 1994;59 Fontana M et al, Act Pediattr Scand 1989

Stool frequency

Countries
USA France England

Bowel movement
1 day 5 day 0-3 months 6-12 month 1-3 years Neonatal 4-6 years 1.5 x/day 4.4 x/day 2.0-2.9 x/day 1.8 x/day 1-2 x/day 3.3 x/day 1 x/day

Thailand

Baker SS, 1999; Osatakul,1995

Frequency of defecation infants 0-4 months of age

Edi S, Hegar B, Firmansyah A, 2003

0
mo 1 mo 2 mo 3 mo 4

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

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

The inverse relation between stool weight and transit time

Diet high in fibre produced large stools more often compare to those on a low-fibre diet who passed small stools less frequently
Reynold JC et al, 1987 Tucker DM et al, Gastroenterology 1991

Fecal consistency infants 0-4 months of age

Edi S, Hegar B, Firmansyah A, 2003

100 90 80 70 60 50 40 30 20 10 0

soft watery

0-4 day

5-14 day

15-113

114-120

Colour of the fecal infants 0-4 months of age

Edi S, Hegar B, Firmansyah A, 2003

100 90 80 70 60 50 40 30 20 10 0 day 1 day 2 day 3 day 4 day 5-14 day15-10

Black yelow green

CONSTIPATION ENCOPRESIS

Constipation

Children < 4 years

< 3 bowel movement per week painful bowel movement rectal impaction abdominal fecal mass on physical examination all four or or or or

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

Constipation
Children > 5 years (at least 2 of the following criteria)
Two or fewer bowel movement per week without laxatives
Two or more soiling/encopresis episodes per week Periodic passage of very large amount of stools once every 7-30 days a palpable abdominal or rectal mass on physical examination

Benninga MA, Thesis 1994

Constipation in infants and preschool children

5-10% (16% < 24 months) children had constipation

Constipation and subsequent fecal retention often begin soon after a child has experienced a painful evacuation Chronic constipation most often follows an inadequately managed acute problem

Infants: tend to extend the body, contract the anal and gluteal muscles Toddlers : rise on their toe, hold their legs and buttocks stiffly
Youssef Nader N, J of Clinical Gastroenterology 2001;33:199-205 Rudolph CD, 1998

Constipation in school age children

The child is brought to medical attention because of encopresis (often of many years duration) or abdominal pain Encopresis
2.8% in the age of 4 year 2.2% in the age of 5-6 years 1.5-19% in the age of 6-11 years 15% in obese children
Fishman L et al, J Pediatr 2004;145;253-4

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

Constipation in children Divisi of Gastroenterology IKA-RSCM 2003

30

25

20

15

10

0 Jan March May Jul Sept Nov total

Encopresis
The voluntary or involuntary passage of a normal bowel movement
in the underwear (or other unorthodox locations) - after the age of four
-

- occurring on a regular basis without any organic cause

Retentive encopresis
Fecal incontinence in children with clear evidence of constipation
Loening-Beucke V, Pediatric Clinnic of North America 1996;43:279-82

Encopresis
Parents often assume that encopresis is caused by the reluctance of the child to use the toilet
The frequency: once or many times a day or intermittent
A periode free of soiling after a large bowel movement Soiling resumes after several days of stool retention

Encopresis is a complication of long standing constipation

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

Conclusion

Defecation pattern in children is a wide range and individual variation Constipation is common in children and it is estimated 5-16% of pediatric patients have constipation and/or encopresis

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