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

1. 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.

4. Disclosure Statement There are no financial conflicts to disclose.

5. 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

7. Normal Frequency of Bowel Movements

8. 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)

9. 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

11. 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

12. 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

14. Important points in history of patient with constipation and encopresisII • 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?

15. 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

16. Epidemiology of Constipation and Encopresis Prevalence: among 7-8 year old children-2.3% 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

17. 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

18. Encopresis: First steps Education Demystification

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

24. 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

25. 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 glycol-electrolyte solution (Golytely) 14-40ml/kg/hr until clear

26. 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

28. 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

29. 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

31. Osmotic laxatives

32. 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

33. Stimulant laxatives

34. 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

36. 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)

37. Fiber Rich Foods

38. 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

39. 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)

40. Table 1. Recommendations for fiber intake during childhood

41. Table 2. Trends in dietary fiber intake during childhood *National Food Consumption Survey #National Health and Nutrition Examination survey

42. Table 3. Fiber containing foods for Children

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

44. 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.

45. Young Children Older Children Mean Grams of Fiber per Day 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).

46. Mean # of Soiling Incidents and Appropriate Bowel Movements per Week Baseline Fiber Toileting 6 Mo. Follow-up 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).

49. Probiotics and constipation • “Dysbiosis” as possible cause of constipation • Probiotics like Bifidobacteriumlactis DN-173010 lowers colonic pH • Lower pH enhances peristalsis • Two RCTs (adults w/IBS and women) showed increased stool frequency

50. Stool frequency per week Fig 3. Change in stool frequency from baseline to after 3 weeks (P = .35) and overall test of stool frequency during treatment (P = .51)