Defecation problems in children with Hirschsprung's disease: a biopsychosocial approach

Abstract

Although most patients with operated Hirschsprung's disease (HD) have good continence in adulthood, a majority have postoperative defection problems during school age. Persistence of chronic constipation and/or incontinence may have considerable consequences for psychosocial development, parent-child interactions, quality of life, and the child's general condition. Considering these consequences, it is important to treat these problems as early as possible. From a biopsychosocial view, we developed a multidisciplinary treatment aimed at resolving defecation problems by teaching the child bowel self-control, primarily by training optimal defecation skills and subsequently toilet behavior. This treatment, carried out by a child psychologist, a pediatric physiotherapist, and a pediatric surgeon, consists of five steps: explanation; extinction of fear and avoidance behavior; learning new defecation behavior; learning an adequate straining technique; and generalization toward daily life. The effect of the treatment was investigated retrospectively in 16 boys with operated HD. The children improved significantly in all aspects during treatment, suggesting that multidisciplinary treatment can significantly reduce the postoperative chronic bowel problems of most children with operated HD. The treatment was as effective in young children (2-5 years) as in older children (5-14 years).

Behavioral Therapy for Childhood Constipation: A Randomized, Controlled Trial

“…This approach is derived from a multidisciplinary BT to treat children with defecation disorders. 22,23 For all involved psychologists, a detailed manual for both age-related modules was available to ensure a standard delivery of therapy. Visits lasted ϳ45 minutes.…”

Hirschsprung’s disease

“…Approximately 15% to 20% of HSCR patients have an unsatisfactory functional outcome following operative repair that persists into young adulthood. The reasons for this finding include hypertensive anal sphincter [24,25], colonic/neorectal dysganglionosis due to either intestinal neuronal dysplasia or hypoganglionosis [26,27], transitional zone pull-through [28,29], fecal incontinence, extracolonic gastrointestinal motility disorder [30], and retentive stool behavior associated with defecation and disease adjustment reactions [31][32][33]. The evaluation of persistent constipation or fecal incontinence in the post-repair HSCR patient is through routine physical examination, contrast radiographs, colonic biopsy, and most recently through colonic manometry [24,34,35].…”

Chronic childhood constipation: A review of the literature and the introduction of a protocolized behavioral intervention program

“…Basic assumption of the behavioral intervention program to treat chronic childhood constipation is that fearful and phobic reactions related to defecation and fecal incontinence can be unlearned and that adequate defecation straining and toileting behavior can be (re)acquired by teaching parents behavioral procedures [17,18,[84][85][86] and by behavioral play therapy with the child [17,18]. Extensive methods from learning theory are applied and a learning process is started in the child and the parents.…”

“…A bowel diary is used to quantify therapeutic progress and to enhance motivation. Based on findings from literature and our large clinical experience, we developed a protocolized behavioral intervention program for constipated children and their parents [16][17][18]. In this article, we extensively describe the key construct and the content of this individual protocolized behavioral intervention program.…”