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DEFECATION PATTERN

IN CHILDHOOD

Badriul Hegar
Divisi of Gastroenterology, Department of Child Health
University of Indonesia

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

There is a wide range and individual


variation in stooling frequency

Inverse relation between gestational age


and the day of the first bowel movement

more than 99% of term newborn infants


pass the first stool within 48 hours

Lorijn F et al, JPGN 2005;40:434-7

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

Bowel movement

USA
France
England

1 day
5 day
0-3 months
6-12 month
1-3 years

1.5 x/day
4.4 x/day
2.0-2.9 x/day
1.8 x/day
1-2 x/day

Thailand

Neonatal
4-6 years

3.3 x/day
1 x/day

Baker SS, 1999; Osatakul,1995

Frequency of defecation
infants 0-4 months of age
Edi S, Hegar B, Firmansyah A, 2003

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

Colour of the fecal


infants 0-4 months of age
Edi S, Hegar B, Firmansyah A, 2003

CONSTIPATION
ENCOPRESIS

Constipation

Children < 4 years

< 3 bowel movement per week


or
painful bowel movement
or
rectal impaction
or
abdominal fecal mass on physical examination
all four

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
infants and preschool children
185 children with constipation:
1st year 3%
2nd years 11%

functional constipation in 97% children


boy and girl were affected with equal frequency

resolved constipation:

dietary changes in 25% children


laxatives
in 92% children
Baucke VL, J Pediatr 2005;146:359-63

Constipation in children
Divisi of Gastroenterology IKA-RSCM 2003

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

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

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

THANK YOU

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