Faecal Incontinence (Soiling)
What is faecal incontinence?
Faecal incontinence is the medical term for soiling in children over the age of 4 years. In most cases faecal incontinence develops as a result of long-standing constipation (Proctor and Loader, 2003). It is estimated that constipation occurs in up to 10% of children (Leung et al, 1996).
The build up of poo in the bowel and rectum results in the bowel getting so stretched that it is unable to register that there is a poo. As a result the usual signal to the brain that they need to go to the toilet is not sent and often the poo comes out catching the child unawares. We call this “sneaky poo”.
Sneaky poo is new, soft poo that moves down the bowel oozing around the hard poo and trickling out. Children with faecal incontinence often wet (day and/or night) as the constantly full rectum affects bladder functioning. Urinary tract infections as a result of this are also common.
In most cases the child is not aware that this happening. The child is not being lazy and punishment will not help solve the problem.
First Steps
* Discuss the problem with your child. Reassure them that they are not the only one with this problem, and, that with their cooperation it can be fixed.
* Read “Tim’s Problem” (available from the NZCA website www.continence.org.nz at a cost of $12). "Poo Hoo" ($18.00) together
* Do some research. Read past newsletters in the KEEA web pages and the information at: www.kidshealth.org.nz
* Visit your family doctor. The doctor will want to know: when the problem started, how often your child does poos, the size and consistency of the poo, whether there is any soiling in their underpants, whether your child has adequate fibre and fluids. They may also want to feel the child’s tummy.
In some cases the doctor may also recommend referral to a paediatrician.
* Contact your local continence advisor. See the “Continence Service Providers” section of the NZCA website to find an advisor in your area.
* If your child attends school contact the Public Health Nurse affiliated with the school (ask at the school office or ring your local Public Health Unit). Public Health Nurses can help with education, resources, toileting programmes, and support for you and your child.
Management
The general rule of thumb is that it will take AT LEAST as long to resolve the problem fully as it did to get constipated, so plan to be managing the problem for months at best to several years at worst.
1. Empty the large intestine and rectum
This is done using softening and stimulating laxatives. These may initially be at frequent, high doses. It will be messy as the old poo comes out so it is best to keep the child home from school while this part of the treatment is carried out.
2. Establish regular bowel movements
This is done by using daily doses of laxatives, sitting on the toilet 15-20 minutes after meals to make the most of the gastrocholic reflex (which increases colonic motility when food passes from the stomach into the upper part of the small intestine), and using a foot stool to relax the pelvic floor muscles when passing a poo.
Keeping track of the poo is important so you will need to keep a poo chart (downloadable from the KEEA pages in the NZCA website www.continence.org.nz).
3. Maintain regular bowel movements long term
Maintenance doses of laxatives, the dose adjusted as needed, are used.
Be alert for signs that the child is becoming constipated again – flatulence, bad breath, soiling underpants, urinary tract infection, sore tummies.
Commonly Used Laxatives
Lactulose
Lactulose softens hard poos making them easier to pass. It works well in mild to moderate constipation. It is not effective on its own in severe constipation when there is a large amount of hard poos backtracking up the colon, but is often used in conjunction with other laxative medications.
Movicol
Movicol can be used in all stages of treatment, for initial disimpaction and the dose adjusted as required to maintain regular bowel motions.
Toilet Routine
Maintaining a regular toileting routine is important. Encouraging the child to sit on the toilet 15-20 minutes after breakfast, lunch and dinner while the gastrocholic reflex is active is recommended. Allow enough time for children who attend childcare or school to sit on the toilet before you leave home. Praise/reward the act of sitting on the toilet rather than any result.
Diet and Fluids
Encourage:
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Good drinking behaviour – 6 evenly spaced drinks of water or water based cordial a day.
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5+ a day servings of fresh fruit and vegetables. Try a “pirate’s” or “princess’s” platter with vege sticks (e.g carrot, zucchini, celery, capsicum, cauliflower) with dip, and seasonal sliced fruit (e.g. apples, pears, plums, pineapple) for morning or afternoon teas.
Exercise
Children aged 5-18 should:
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Throughout each day, do 60 minutes or more of moderate to vigorous physical activity;
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Be active in as many ways as possible; for example, through play, cultural activities, dance, sport and recreation, jobs, and going from place to place;
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Be active with friends and whanau, at home, school, and in your community; and
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Spend less than 2-hours a day (out of school time) in front of television, computers and game consoles.”
(Guidelines from Sport and Recreation NZ - www.sparc.org.nz)
References:
Proctor, E and Loader, P “A 6-year follow up study of chronic constipation and soiling in a specialist paediatric service” Child: Care, Health and Development” 29 (2) 103-109
Leung, AK, Chan, PY, Cho HY “Constipation in Children” American Family Physician 1996 Aug 54(2) 611-8, 627
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