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DEFECATION PATTERN
IN CHILDHOOD
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A normal recto-anal inhibitory reflexes only in newborn after 26weeks 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 fordefecating in the accepted place
Volun tary bowel con tro l
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Breast fed infants had more bowel movement with
a greater range in number,butby 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 ~ m ilk intake
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Stoo l frequency ~ age
A decline in the frequency of defecation withage
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
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Countries Bowel movement
USA
FranceEngland
Thailand
1 day 1.5 x/day
5 day 4.4 x/day0-3 months 2.0-2.9 x/day
6-12 month 1.8 x/day
1-3 years 1-2 x/day
Neonatal 3.3 x/day
4-6 years 1 x/day
Stool frequency
Baker SS, 1999; Osatakul,1995
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Frequency of defecat ion
infants 0-4 mon ths of age
0
1
2
3
4
5
mo 1 mo 2 mo 3 mo 4
Edi S, Hegar B, Firmansyah A, 2003
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Consis tency of stoo l
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 oftencompare to those on a low-fibre diet who passed small
stools less frequently
Reynold JC et al, 1987
Tucker DM et al, Gastroenterology 1991
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0
10
20
30
40
50
60
70
80
90
100
0-4 day 5-14 day 15-113 114-120
soft
watery
Fecal consistency
infants 0-4 mon ths of age
Edi S, Hegar B, Firmansyah A, 2003
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0
10
20
30
40
50
60
70
80
90
100
day 1 day 2 day 3 day 4 day 5-14 day15-10
Black
yelow
green
Colou r of the fecal
infants 0-4 mon ths of age
Edi S, Hegar B, Firmansyah A, 2003
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CONSTIPATION
ENCOPRESIS
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Const ipat ion
Children < 4 years
< 3 bowel movement per week or
painful bowel movement or
rectal impaction or
abdominal fecal mass on physical examination or
all four
Loening-Beucke V, Constipation in early childhood, Gut 1993;34:1400-4
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Const ipat ion
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
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Const ipat ion in
infants and preschool ch i ldren
5-10% (16% < 24 months) children had constipation
Constipation and subsequent fecal retention often beginsoon after a child has experienced a painful evacuation
Chronic constipation most often follows an inadequatelymanaged acute problem
Infants: tend to extend the body, contract the anal and
gluteal muscles
Toddlers : rise on their toe, hold their legs and buttocksstiffly
Youssef Nader N, J of Clinical Gastroenterology 2001;33:199-205
Rudolph CD, 1998
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Cons t ipat ion in school age ch i ldren
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 ch i ldren
Fishman L et al, J Pediatr 2004;145;253-4
Loening-Beucke V, Pediatric Clinnic of North America 1996;43:279-82
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0
5
10
15
20
25
30
Jan March May Jul Sept Nov total
Cons t ipat ion in chi ldren
Divis i o f Gastro enterolog y IKA-RSCM 2003
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Encopresis
The voluntary or involuntary passage ofa normal bowel movement
- in the underwear (or other unorthodox locations)
- after the age of four
- occurring on a regular basis without any organiccause
Retentive encopresis
Fecal incontinence in children with clear evidenceof constipation
Loening-Beucke V, Pediatric Clinnic of North America 1996;43:279-82
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Encopresis
Parents often assume that encopresis is caused bythe reluctance of the child to use the toilet
The frequency: once or many times a day orintermittent
A periode free of soiling after a large bowel movement
Soiling resumes after several days of stool retention
Encopresis is a complication of long standingconstipation
Loening-Beucke V, Pediatric Clinnic of North America 1996;43:279-82
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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
Conclus ion
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THANK YOU
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