Current practice for assessment and treatment of faecal incontinence in children
Authors Anne Weaver, RGN, is clinical assistant; Penny Dobson, MSc, CQSW, RGN, is director; both at ERIC (Education and Resources for Improving Childhood Continence), Bristol.
ABSTRACT Weaver, A., Dobson, P. (2007) An overview of faecal incontinence in children. Nursing Times; 103: 47, 40–42.
Anne Weaver and Penny Dobson outline the current practice for assessment and treatment of faecal incontinence in children.
Faecal incontinence is an embarrassing and stressful condition for children and families. Studies also show it affects 3.5% of boys and 1% of girls aged 5 years and 1.2% of boys and 0.3% of girls aged 10–12 years (Lukeman, 1997). Chronic constipation is often the underlying cause and accounts for 25% of all referrals to paediatric gastroenterology outpatient clinics (Youseff et al, 2001).
The Paris Consensus on Childhood Constipation Terminology Group (PACCT) published new standardised working definitions (Benninga
et al, 2005).
The terms soiling and encopresis were often used interchangeably and both have now been replaced by the general term faecal incontinence to define the passage of stools in an inappropriate place.
Faecal incontinence can be either organic, as a result of neurological damage through trauma or congenital conditions such as anal sphincter abnormalities, or functional in origin. It is reported that 95% of children who are incontinent of faeces have functional constipation with overflow (Price and Elliott, 2001).
Functional faecal incontinence is subdivided into constipation-associated faecal incontinence and non-retentive faecal incontinence.
Chronic constipation is diagnosed if two or more of the following symptoms are present for eight weeks (Benninga et al, 2005):
Fewer than three bowel movements per week;
More than one episode of faecal incontinence per week;
Presence of large stools in the rectum or palpable on abdominal examination;
Production of large stools that obstruct the toilet;
Indications in the child’s posture and behaviour that they are withholding stools;
The definition of faecal impaction is constipation with a large faecal mass in the rectum or the abdomen that is unlikely to be passed spontaneously.
Non-retentive faecal incontinence is defined as ‘the passage of stools in an inappropriate place by a child with a mental age of four years and older, with no evidence of constipation by history and/or examination’. In some cases, emotional factors such as anxiety trigger the accidents and the child is unaware when this happens (Bonner, 2003), or it might be that the child has simply never achieved toilet training for the bowel and there is no underlying emotional cause. This would include children with an autistic spectrum disorder or other learning disability. There are some children who deliberately pass faeces in an inappropriate place. They require a specialised behavioural approach, perhaps through referral to the child and adolescent mental health service. In the past, this was referred to as ‘true encopresis’.
When stools are difficult or painful to pass, a child may be reluctant to defecate and ‘holds on’ to the stools by contracting the external sphincter. The brain then begins to ignore the signals that would usually alert a child to the need to empty and the stools build up in the rectum and colon.
This can result in the child passing large stools very infrequently, causing further pain and even anal tears; there may also be overflow diarrhoea, as a result of watery faeces leaking around the harder stools.
The child has no control over this and will often be unaware that they have soiled. This can happen up to 10 times a day and it can be difficult for parents to accept that there is an underlying constipation when stools appear so loose. Factors that predispose a child to constipation are listed in Box 1.
Effects on the child and family
Faecal incontinence is sometimes perceived as being a behavioural problem, leading to parents and children feeling that they are somehow to blame. The associated shame and embarrassment can lead to avoidance of social situations and feelings of isolation, often for the whole family. A recent study that analysed data from 8,000 parents and children found significantly higher rates of behaviour and emotional problems, bullying and antisocial activities in children who have the problem compared with those who do not (Joinson et al, 2006).
Many parents are unsure where to go for help. The health visitor or school nurse therefore has a valuable role in supporting and guiding families through the often difficult process of understanding the condition and following a treatment programme. Treatment can be effectively carried out in the primary care setting, with the GP or community paediatrician carrying out a physical examination to exclude other causes, identify any underlying constipation and initiating a treatment programme. Further referral and the need for specialist hospital appointments is greatly reduced if there is an effective programme with ongoing contact and support from the community nurse.
A full history is paramount to successful treatment and this should include:
A baseline chart of stools passed in the toilet and soiled pants, using the Paediatric Bristol stool chart (Norgine, 2005), to be kept for one week prior to assessment to provide information about the frequency and nature of the problem;
History of toilet training, abdominal pain and signs of ‘holding’ strategies;
Diet and fluid intake;
Family, social and environmental factors;
School attitudes and availability of quality toilet facilities and access to palatable drinking water;
Feelings of the child and psychological issues, such as anxiety about using the toilet or fear of pain;
Family attitudes and their understanding of the problem;
Educational or physical needs affecting the child, such as learning difficulties or mobility problems.
A general examination should include:
Checks on general growth and development to exclude possible failure to thrive, or neglect;
An abdominal examination. This can detect faecal impaction but is not always conclusive. Rectal examination is not recommended for children and is of little value. A plain abdominal X-ray is not required routinely but may be indicated in some cases (Felt, 1999);
Observation of the external sphincter and anus for fissures, soreness or abnormalities (sexual abuse should be considered, although there are usually a number of worrying indicators, in addition to the soiling, that would alert doctors to this possibility);
Check the lower back, spine and lower limb reflexes for signs of a congenital problem such as Hirschsprung’s disease (an absence of neural ganglions in the wall of the bowel), anal stenosis or spinal nerve damage. These need to be ruled out but are unlikely if there were normal bowel actions in the neonatal period and early infancy.
The principles of treatment to clear the impacted bowel with oral laxatives, prescribe a maintenance dose to prevent further constipation and establish a toileting and dietary regimen to ensure the child passes regular stools. There may be setbacks, so it is vital that the nurse is there to give encouragement to continue with the programme and avoid the ‘cycle’ of recurring constipation that leads to the problem starting all over again.
Medication to clear the impacted bowel
The five main types of laxatives are:
Iso-osmotic agents, such as macrogol 3350 and electrolytes (Movicol Paediatric Plain) (Vincent et al, 2001);
Faecal softeners, such as docusate;
Osmotic laxatives, such as lactulose;
Stimulant laxatives, such as senna, sodium picosulphate or bisacodyl;
Bulking agents, such as Fybogel (not used for clearing impaction).
The medication should suit the individual child and prescribed with clear information about how it works, dosage and the importance of continuing with the medication until advised to stop by the prescriber. The dosages must be sufficient to ensure that the bowel is completely cleared. For example, Movicol Paediatric Plain should be given in increasing doses until this is achieved, which can take five to seven days. Occasionally, children may require hospital admission. Suppositories, enemas and manual removal of faeces are not considered appropriate for children.
It is recommended laxatives are then continued at a maintenance dose for up to a year, as stopping medication too soon can precipitate relapse (Clayden, 1996). Bowel actions should be recorded using the Bristol stool scale so that dosages can be adapted to maintain a normal easy-to-pass stool.
Other changes in care:
Encourage parents to establish a regular toilet routine;
Create regular times for the child to sit on the toilet (wait 15–20 minutes after meals);
Use a step to support the feet and a child-size toilet seat to ensure the child can sit securely;
Make time spent in the toilet special and fun (using incentives such as a ‘lucky dip’ bag of items – party blowers and bubble tubs can be effective);
Keep a record of all stools passed in the toilet;
Reward the child for using the toilet;
Use the rock ‘n’ pop technique of gently rocking backwards and forwards to increase the chance of producing a stool (see ERIC leaflet Get Going).
Increase dietary fibre. Suggest a diet that includes a balance of fruit, vegetables and cereals and foods containing fibre. Some children have to be coaxed to eat different foods.
Increase fluid intake. Encourage six to eight drinks a day of water-based fluid and ensure the child has good access to palatable drinking water at school. There is some evidence of a link between constipation and allergy to cow’s milk (Iacono et al 1995). Advice from a paediatric dietitian is advisable if constipation follows the introduction of cow’s milk.
Encourage exercise on a regular basis. During the 15–20 minutes after meals and before sitting on the toilet, encourage the child to help clear the table or be active in some other way.
Children who do not respond to management in the primary care setting may need to be referred to a paediatric gastroenterologist. However, good follow-up in the community will still be needed between appointments and on discharge to ensure that families understand the importance of continuing with treatment to prevent recurrence.
Input from the Child and Adolescent Mental Health Service (CAMHS) may be required if there are behavioural issues, such as lack of self-esteem or bullying, or if there is a psychological issue. Communication between all health professionals is essential and joint working is often helpful.
The child’s school
It is important that the school staff have an awareness of the principles of treatment and the individual needs of the child. They also need to understand that faecal incontinence is outside the child’s control. The school nurse and head of pastoral care need to ensure that the child is supported in a discreet and confidential way, with good access to toilet and drinking facilities and a changing bag containing clothing, wipes and disposal bags provided from home. Setting up a written individual care plan with the child, family and teaching staff can help the school manage a toileting and changing routine, in line with school policies on health and safety and equal opportunities.
There are published guidelines to help schools to develop policies on good practice for the safety and well-being of staff and children when dealing with children with toileting problems (Rogers, 2006).
Children with additional needs
Children with special physical needs or learning disabilities can take longer to achieve bowel control. They may have toileting difficulties due to behavioural issues such as toilet refusal or a phobia. Children with a recognised diagnosis should be assessed and helped with toilet training at an early stage. They should always be assessed to exclude constipation as they may respond well to a treatment programme if this is introduced in a planned and careful step-by-step way.
The incidence of unusual toileting behaviour, including stool holding, is known to be higher in children with neurodevelopmental disorders, such as autistic spectrum disorders. Occasionally the toileting problem is the first indication of an underlying condition which requires follow-up.
Box 1: Factors that predispose children to constipation
Price, K.J., Elliott, T.M. (2001) Stimulant laxatives for constipation and soiling in children. Cochrane Database of Systematic reviews; 3: Art. No. :CD002040.DOI: 10.1002/14651858.CD002040.
Rogers, J. (2006) Managing Bowel and Bladder Problems in Schools and Early Years Settings – Guidelines for Good Practice. Manchester: Promocon. www.promocon.co.uk
Vincent, R. et al (2001) Movicol for the treatment of faecal impaction in children. Gastroenterology Today; 11: 2, 50–52.
Youseff, N.N. et al (2001) Childhood constipation: evaluation and treatment. Journal of Clinical Gastroenterology. 33: 3, 199–205.