Discussion
Currently, the key aspects of treatment for FC include the use of laxatives, dietary modifications, behavioral therapy, and so on.2 In infants, oral and/or rectal laxatives and probiotics are the first-line treatments for fecal impaction.8 However, the symptoms of patients with IFC often persist, and relapses are common.9 The quality of life is adversely affected in various aspects including social interactions, school achievements, and self-esteem. And finally, surgery decisions were made in the management of children with IFC in many centers.4 10
Nowadays, the optimal time of toilet training for infants is still controversial between eastern and western countries.11 In Chinese culture, early toilet training is practiced as it helps the parents to make the infants aware about the sensory of defecation, gives sufficient time for the infant to get adapted to toilet training, and makes the transition to independent toileting easier for the infants.12 In the past, the ‘infant toilet training’ approach received a lot of media attention, but it was infrequently used in routine clinical practice and was not discussed in the published guidelines.13
In the current study, the toilet training program was started as early as 3 months of age. During the follow-up period we found that most infants benefited from promoting intestinal peristalsis and stimulating defecation, and they were trained to control stool activities spontaneously, including the muscles involved in defecation, and to establish a defecation reflex.14 15 Clinically, the ability to control the defecation and to achieve coordinated rectal muscle contraction with sphincter relaxation matures over time.16 Undoubtedly, toilet training accelerated this process.
Furthermore, the treatment method of toilet training program was also varied. For a long time, anal stimulation is considered to be less invasive and commonly employed in China, and use of mechanical stimulants, such as soap or cooking oil, or other types of anal stimulation, was popular. By using daily anal stimulation as a part of toilet training process, the effect is generally believed to present recognizable motility pattern and to stimulate colonic propagated contraction (‘colo-anal reflex’).17 Finally, the aim is to promote defecation regularly and to build proper toilet habits. To the best of our knowledge, this is the first study to evaluate the effects of daily anal stimulation in infants with IFC.
At the same time, all the parents were provided with health education and psychological counseling. The anxiety and depression of parents were relieved, and trust was created between doctors and patients, so as to obtain their full cooperation and compliance. Therefore, the process of intervention could be performed in a pleasant and encouraging environment. Furthermore, besides mechanical anal stimulation, close touch from caregivers, such as specific whisper nursery rhymes and soft abdominal massage, could also arouse defecation awareness and could play important roles in the onset of toilet training with more sensitive approaches.12
ARM is an effective tool to assess anorectal sensations, pressure changes, and rectal compliance.18 In this study, we evaluated the manometric parameters in infants to detect possible changes in the defecation dynamics and anorectal neuromuscular functions before and after intervention. All children had intact RAIR, which is important to exclude HSCR and IASA. The frequency of peristalsis in the distal rectum was similar before and after intervention. However, the peristaltic wave of distal rectum was disorganized, with slow, irregular waveform and low amplitude before intervention. After intervention, the amplitude of peristalsis became significantly greater and the rhythm also significantly improved (table 2). These findings suggested that with intervention the intestinal peristalsis improved and the coordination function of defecation was obviously strengthened. The mean resting pressure measured in a quiet state mainly reflects the tension of the internal sphincter. A normal sphincter apparatus helps patients to achieve control over the muscles of the defecation.19 Although normal values for ARM have been published in adults, there have been few studies reporting the manometric data of normal and constipated infants. In this study, there was no significant difference in the anal resting pressure before and after intervention. This means that the intervention, including anal stimulation, did not adversely impact the structure and function of the internal sphincter.20
In order to support the management program and to enhance compliance, all patients underwent monthly clinical visits during the first year of follow-up. We found that most patients had improvement in defecation lasting at least 1 year suggesting that the toilet training had a beneficial response. Three patients had recurrence of symptoms over 6 months and required colectomy. Among these patients, two had IND and one had hypoganglionosis on histopathology of the resected colon. These are rare entities of congenital neuronal intestinal malformation and are classified as variants of HSCR.21
This study found that daily anal stimulation was one treatment of the early toilet training program (as early as 3 months of age) and might be an effective strategy for the management of infants with IFC. It triggers defecation regularly and effectively builds proper toilet habits.
There were some limitations in the present study. First, retrospective single-center research was the main limitation; then, uncontrolled study and short-term follow-up also limited our results and conclusion. Therefore, future prospective randomized controlled trial studies are required to validate our findings and to further improve the outcomes.