User:Aberpete/soiling

Soiling or Encopresis or faecal incontinence in children is the involuntary passage of stools in children over 4 years of age.

• It is a common problem among children. Boys are 3 times more often affected than girls.
• It is a major problem for the children and their parents, but its significance is often underestimated.
• In the Past soiling was attributed to an underlying psychological disorder. However studies have failed to identify a psychological cause. But there is evidence that the psychological abnormalities associated with soiling are a result of it rather than a cause. Resolution of behavioural problems has been demonstrated when soiling is successfully treated.
• Like Bedwetting, soiling can be divided into primary and secondary: Primary soiling is when the child has never been clean. Secondary soiling occurs in children who have already been toilet-trained, but start to soil again.

Causes

• Soiling is in the vast majority of cases a functional problem caused by a vicious circle of constipation and stool withholding.
• Psychological causes, like ADHD or ODD, play a much lesser role in the origen of soiling as traditionally thought, but it may be associated with it.
• Organic causes for primary soiling include Spina bifida, Hirschsprung's disease, or Surgery.
  • Spina Bifida can cause soiling, but there are often other neurological defects too.
  • Hirschsprung's disease can cause soiling, but is not usually associated with soiling.

Mechanisms of Constipation: A Vicious Circle leading to Soiling

Overflow-Incontinence

1. Constipation is associated with hard, large stools in the colon (=large bowel) and rectum,
2. which become difficult and painful to evacuate (Defecation).
3. This leads to stool-withholding.
   • Other causes for stool-withholding may be rooted in a reluctance of the child to go to the toilet due to disgust or irrational fears (e.g. monsters).
4. The rectum becomes gradually distended with accumulated stool.
5. The distension causes a loss of sensation in the rectum. This leads to further stool-withholding, as the urge to defecate becomes more and more irregular.
6. Eventually, softer stools from higher up the bowels cannot be accommodated and leak around the bolus of hard stool (overflow).
   • Due to the lack of rectal sensation, this is not noticed by the child until soiling has actually occurred.

Emotional Consequences

Parents are under great stress, as they might think or suspect that their child is soiling intentionally and become irritated and even aggressive. They might have also been advised that their child is psychologically abnormal, which leads to further distress.

Both Parents and Child often suffer great psychological abuse. Soiling can result in a disruption of relationship between the parents as well as the parents and their child.

Children who soil then become very frightened as they are punished for something over which they have no control. Soiling results in a marked loss of self-esteem in the affected children. Behavioural abnormalities can develop.

Typical features

• Several soft stools daily. (Parents of constipated children often insist that their child is having diarrhoea rather than constipation, and it may be difficult to convince these parents, that their child should go on treatment for constipation.)
• Occasional very large stools.
• Painful defecation
• Blood in Stools (this is usually due to painful anal fissure in anus)
• Stool-withholding behaviour: Child may be noted to spend long periods of time standing in a corner prior to soiling. This can be mistaken for exaggerated attempts at defecation, and might foster the believe that soiling was intentional.
• Children are usually noted to be tired, pale looking, and beiing irritable.

Consultation with the doctor include:

History taking:

• Enquiry about the symptoms (above) in order to come to a positive diagnosis of Constipation.
• Review of the developmental milestones: Markedly delayed milestones or the presence of any major psychological abnormalities may hint at a cause other than constipation for soiling.
• A delay in the passage of meconium in the neonatal period could be a symptom of Hirschsprung's disease.

Physical Examination:

• Abdominal examination: The impacted bowels may be felt through the tummy, but is often not felt even in severe constipation.
• Close inspection of the Anus and perianal area: Anal fissures (=Anal tears) will support the diagnosis. There may also be signs of inflammation like Thrush (=Candidiasis) or Streptococcal infection.
• The Back should be inspected and ankle jerk reflexes tested to rule out spina-bifida.
• (A rectal examination should not be performed, especially not in young girls. The children are already traumatised enough in this area, and this would be one more emotional trauma. It also provides no useful information, as the rectum might be empty at the moment of examination.)

Management:

Soiling should always be treated as secondary to constipation (even if in doubt of another cause): 70-75% success

1. Education and Reassurance: (Relieves anger and anxiety from parents and child.)
   • Soiling is not intentional. (Child doesn't notice until soiling has occurred.)
   • Child is not psychologically abnormal. (Behavioural problems will resolve once soiling has been treated successfully.)
   • It can be treated successfully.
   • Explain mechanisms of overflow-incontinence with picture (It is important for parents to understand the mechanisms of soiling well, as they might otherwise not comply with treatment, leading to treatment-failure)
   • Involve Children if old enough. (Parents of children who have been toilet-trained for a few years have little idea about their child’s bowel habits, although they often assume great authority on the issue)
     
     
2. Disimpaction: Removal of the hard impacted stools in the rectum with a strong Laxative (start when child is off school or nursery.) - e.g.:
   • Bisacodyl orally 5 mg in mornings for 3 days (10 mg if over 5 years of age)
   • (Enemas or Suppositories are invasive and are usually not needed. Success of treatment depends on its consequent and prolonged application, not on its invasiveness)
     
     
3. Prevention of Reaccumulation: with a stool softener (start simultaneously with disimpaction) For 6-12 months for child to regain confidence and colon to return to original tone and shape. It is important to do this consequently, in sufficiently high doses and for a sufficient length of time. Taper off treatment gradually after. - e.g.:
   • Liquid Paraffin (= mineral oil) (10 - 60 mls at night) titrated to effect (directly from fridge, with yoghurt or ice-cream) (Contraindications: Children <1 year and children with neurological abnormalities or learning difficulties should not take Liquid Paraffin, because of risk of pulmonary aspiration)
   • Lactulose may be used in infants <1 year of age (It is less suitable because of day-to-day inconsistency of efficacy, making it difficult to titrate and possibly counterproductive to establish regular bowel pattern)
   • Dietary fibre (e.g. fruits) + Plenty of Fluids are important, but on its own these measures will not be sufficient enough once stool withholding and soiling have established!)
   • (NO enemas or suppositories. These are for Disimpaction only. If hard stools have formed again, it means that reaccumulation has occurred and higher doses for its prevention are needed.)
     
     
4. Establishing regular bowel pattern: (start after successful disimpaction)
   • Encourage child to sit on toilet regularly, at same time of day, at least once, for at least 5 min, Ideally after breakfast (gastro-colic reflex)
   • Continue on daily basis irrespective on whether or not child has passed stools.
   • Footstool or other support to ensure hips can be fully flexed, and child can sit comfortably on toilet

References

• The original article has been broadly based on a lecture for students given by Prof. Brendan Drumm, Consultant Gastroenterologist, Head of Department of Paediatrics, University College Dublin
• Constipation in infants and children: evaluation and treatment. A medical position statement of the North American Society for paediatric Gastroenterology and Nutrition
• Paper for the above: by Baker SS, Liptak GS, Colletti RB, Croffie JM, Di Lorenzo C, Ector W, Nurko S
• Liquid paraffin: a reappraisal of its role in the treatment of constipation by F Sharif, E Crushell, K O'Driscoll, B Bourke

Category:Gastroenterology Category:Pediatrics