12 Elimination Patterns
Gastrointestinal (GI), renal, urinary, and integumentary systems function to eliminate metabolic by-products and body wastes. This chapter discusses normal bowel and bladder function, normal developmental activities such as toilet training, and behaviors that are often self-limited in young children but can require intervention (e.g., encopresis and enuresis). Problems related more directly to GI and renal pathology are presented in Chapters 32 and 34. Dermatologic conditions are discussed in Chapter 36.
Standards
The American Academy of Pediatrics (AAP) and the U.S. Preventive Services Task Force (USPSTF) do not recommend routine urinalysis for asymptomatic children; screening urinalysis should be conducted based on a specific clinical symptom or condition (AAP and Bright Futures, 2007; USPSTF, 1996). The AAP recommends that toilet training begin when the child is ready, which is not before 18 to 24 months of age (Wolraich and Tippins, 2003).
Normal Patterns of Elimination: Bowel and Urinary
Infants
Bowel Patterns
Bowel patterns of infants are related to the frequency and amount of feeding and differ between formula-fed and breastfed babies. Breastfed infants commonly have many small stools per day in the first weeks of life; frequent stooling in the neonate is an indicator of adequate breast milk intake (Shrago et al, 2006). During the second month of life infant stooling decreases markedly, from a median of six stools to one stool per day; nearly 40% of infants do not stool every day (Bekkali et al, 2009a; Tunc et al, 2008). Some older breastfed infants may stool as infrequently as once every 8 to 14 days. In exclusively breastfed infants, infrequent stooling is not a problem; if the infant is thriving, happy, and has no clinical signs (e.g., abdominal distention, irritability, vomiting), parents can be reassured that it is transient. The stools of breastfed infants are usually soft, sticky, or watery with a curdlike texture, light yellow, and have a “sour” but not unpleasant odor. Iron supplements can darken the stool and make it firmer.
Formula-fed babies have two to four stools each day in the first month. As patterns become established, the number of stools decreases and older formula-fed infants may have one to three soft semiformed stools each day. Stools of formula-fed infants are firmer, darker, and smellier than those of breastfed infants. They may be brown, greenish, or dark yellow depending on the type of formula and whether it is iron-fortified or if the child is given iron supplements. The stools of both breastfed and formula-fed babies become firmer, darker and more predictable as solid foods are introduced.
Urinary Patterns
Urination is associated with fluid intake, increasing as infants take more fluids. Healthy, well-hydrated infants, whether breastfed or formula-fed, should urinate a minimum of 6 times a day but can void in small amounts as many as 15 to 20 times a day. Fever in infants can quickly lead to dehydration, with less frequent urination.
Voluntary bowel and bladder control depends on myelination of the pyramidal tracts in the spinal cord, a process probably completed between 12 and 18 months of age. Infants 9 to 12 months old generally have regular patterns; they may have a bowel movement early in the morning or after feeding or stay dry for several hours and urinate immediately after waking from a nap. Parents may use these regular patterns to begin introducing the toddler to toilet training, and some parents will place the younger child on the “potty” when the child shows elimination cues.
Toddlers and Preschoolers
Bowel Patterns
Toddlers and preschoolers usually have a regular pattern of elimination. Although they typically have one to three stools a day, it is not unusual for children in this age group to defecate every other day or every third or fourth day. It is a myth that healthy children must have a bowel movement every day. Normal stools have an unpleasant odor and are soft, formed, and various shades of brown, depending on the child’s diet.
Urinary Patterns
By the time children are 2 years old, renal function is fully developed. The urinary pattern of toddlers and preschoolers is influenced by fluid intake, environmental conditions, perspiration, fever, and diarrhea with significant fluid loss. They typically urinate 8 to 14 times a day. Cold weather, excitement, and stress lead to increased frequency. Children generally do not void during sleep after 18 months (Jansson et al, 2005).
School-Age Children
Bowel Patterns
Elimination patterns in school-age children approximate those of adults. Depending on intake, a child may have bowel movements from one to three times a day to once every 2 to 3 days. Stool is soft, formed, and brown and has an odor. School-age children should be completely toilet trained, although occasional soiling of underwear occurs as a result of poor hygiene or because children do not respond quickly to defecation cues. During the school-age years it is important to be cognizant that children increasingly need independence and privacy; these needs extend into the arena of toilet management.
Urinary Patterns
School-age children have essentially the same capacity as adults to produce urine—between 650 and 1500 mL in a 24-hour period—but the kidneys are still small and accommodate a smaller urine volume at any one time than those of adults. Children normally void 5 or 6 times a day. Girls appear to have slightly larger bladder capacity than boys. Dysfunctional voiding (too little means 1 to 3 times a day; too much means 8 to 12 times a day), daytime incontinence, or nocturnal enuresis warrants further evaluation, especially because these conditions can be associated with infection, dehydration, constipation, or sexual abuse.
Adolescents
Bowel and Urinary Patterns
GI and renal functions are at adult levels in adolescents, and patterns of elimination are similar to those of adults. Abnormal variation can occur in teenagers who have eating disorders. Adolescents are also susceptible to the demands of schedules, stress, and irregular eating patterns. The need for privacy, safety, and personal space can inhibit normal elimination in public places, such as school or dormitory restrooms (Kistner, 2009). Sexual activity can contribute to changes in bowel or bladder function, including infections or constipation.
Assessment of Patterns
Assessment of elimination patterns begins with a thorough health history with questions being asked of the parent or the child, depending on the child’s age and ability. As variations of normal behavior become evident, relevant follow-up questions should be asked to clarify and complete the health picture.
Health History
Description of Current Status
The patient’s current elimination status can be assessed with the following questions:
• How often does your child urinate? How many wet diapers does your baby have in a 24-hour period?
• How often does your child have a bowel movement? Describe what the stools look and smell like. How does your child act when having a bowel movement?
• Describe anything unusual about your child’s elimination habits. Does your child resist going to the bathroom?
• Describe your child’s toileting habits. For example, at what time of day does your child have a bowel movement?
• Do you use any medications, including over-the-counter preparations or home remedies, to help your child with bowel movements?
• How do you think the process of toilet training will happen (ask of parents of a 9- to 12-month-old child)?
• Is your child toilet trained? When did training begin? Describe the process. How often do “accidents” happen? How do you (parent) feel toilet training is progressing?
• What names do you use in your family for stool and urine, for body parts, and for the process of using the toilet?
Birth History
Determine whether any problems with the child’s urine or stool were present at birth. For example, did the baby pass a meconium stool within 48 hours after birth? How soon after birth did the baby urinate?
Review of Systems
The review of systems should include the following questions:
• Has your child ever been constipated or had diarrhea? How does the parent define constipation and diarrhea? (Box 12-1 summarizes the Rome III criteria for functional constipation. See Box 12-2 for the Bristol Scale of stool quality that reflects colonic transit time.) Is it chronic or occasional? Did it start after a particular incident (e.g., illness, during toilet training, with a certain food or change in diet)?
• Has your child ever had a urinary tract infection (UTI)? Describe. Any workup (e.g., ultrasonography [US], urethrogram), findings, treatment, and follow-up?
• Has your child had any illness, injury, or operation related to the bowel or bladder? Describe.
• Does your child have a physical condition or chronic illness that affects voiding or bowel movements?
• Is there a history of bed-wetting; at what age did it resolve?
BOX 12-1 Rome III Criteria for Functional Constipation: Infants and Children
Child must have at least two of the following criteria, at least once a week, for at least 1 month (infants to 4 years old) or for at least 2 months (children over 4 years old); with no evidence of structural, metabolic, or endocrine disease:
• Two or fewer defecations per week
• At least one episode of fecal incontinence per week (after child is toilet trained)
• History of excessive stool retention, retentive posturing in children 4 or more years old
• History of painful or hard bowel movements
• History of large-diameter stools, could obstruct toilet
From Rome Foundation: Rome III diagnostic criteria for functional gastrointestinal disorders. Available at www.romecriteria.org/criteria (accessed Aug 9, 2011).
BOX 12-2 Bristol Stool Form Scale
Adapted from Choung RS, Locke GR 3rd, Zinsmeister AR, et al: Epidemiology of slow and fast colonic transit using a scale of stool form in a community, Aliment Pharmacol Ther 26(7):1043-1050, 2007.
| Type 1 | Separate hard lumps, like nuts | Slow colonic transit |
| Type 2 | Sausage-shaped but lumpy | Slow colonic transit |
| Type 3 | Sausage or snakelike but with cracks on surface | Normal colonic transit |
| Type 4 | Sausage or snakelike, smooth and soft | Normal colonic transit |
| Type 5 | Soft blobs with clear-cut edges | Normal colonic transit |
| Type 6 | Fluffy pieces with ragged edges, mushy stool | Fast colonic transit |
| Type 7 | Watery, no solid pieces | Fast colonic transit |
Family History
Determine whether any family members, including parents, have had problems with urination or bowel movements and describe them (e.g., chronic constipation or diarrhea, bed-wetting). Has the child or family traveled or lived outside the U.S.? Does the family residence use well water?
Environment and Psychosocial Issues
Environmental and psychosocial issues should be assessed, using questions such as:
• How do you, as a parent, feel about the issue of toileting?
• How do you interact with your child around toileting issues?
• How do you deal with toileting “accidents” (including bed-wetting)?
• What plans do you have for managing toilet training?
• Describe your child’s typical diet.
• Tell me about the toileting facilities at your child’s house, daycare, and school. How do you think they affect your child’s toileting habits?
Physical Examination
The physical examination includes external examination of the perineum, anus, and urinary meatus and auscultation and palpation of the abdomen for bowel sounds, softness, masses, peristalsis, and tenderness.
Management Strategies for Normal Patterns
Toilet Training
Toilet training occurs in the toddler and preschool years and is usually complete by 4 years of age. Successful toilet training requires sensitivity, understanding of development, good communication, hope, humor, and patience. In addition to becoming self-sufficient in their toileting, children should also learn that elimination is a natural and necessary process. As self-toileting is mastered, parents and children should experience pride and satisfaction in having worked together to accomplish an important developmental task.
The health care provider plays an important role in providing anticipatory guidance to parents. Introduce the topic of toilet training at the 9-month visit and again at 12, 15, and 18 months; assess parents’ expectations and plans and provide ample opportunity for discussion of realistic toileting outcomes.
When to begin toilet training is a perennial question of parents. Providers can emphasize that every child is unique, and readiness cues should ultimately be used to decide when to begin training. Physiological readiness develops by about 18 months. True voluntary sphincter control is a function of psychological and social development as well, so most children are not usually ready for independent toilet training until 24 months or even older. Guidelines for assessing toilet-training readiness include physical, cognitive, interpersonal or psychological, and parental skills (Table 12-1).
TABLE 12-1 Guidelines for Assessing Readiness to Toilet Train
| Skills to Assess | Criteria |
|---|---|
| Child’s physical skills | Has voluntary sphincter control |
| Stays dry for 2 hours, may wake from naps still dry | |
| Is able to sit, walk, and squat | |
| Assists in dressing self | |
| Child’s cognitive skills | Recognizes urge to urinate or defecate |
| Understands meaning of words used by family in toileting | |
| Understands what the toilet is for | |
| Understands connection between dry pants and toilet | |
| Is able to follow directions | |
| Is able to communicate needs | |
| Child’s interpersonal skills | Demonstrates desire to please parent |
| Expresses curiosity about use of toilet | |
| Expresses desire to be dry and clean | |
| Parental skills | Expresses desire to assist child with training |
| Recognizes child’s cues of readiness | |
| Has no compelling factor that will interfere with training (e.g., new job, move, family loss or gain) |
Over the past 4 decades, the median age to begin toilet training in the U.S. has increased from less than 18 months to between 21 and 36 months; some studies show no benefit to beginning training before 27 months (Choby and George, 2008). Internationally, the age of initiating toilet training has also increased (Mota and Barros, 2008; Vermandel et al, 2008). In the U.S., race and socioeconomic status may influence the decision about when to begin toilet training, with one study showing that higher-income Caucasian parents view 25.4 months as an appropriate age in contrast to African-Americans (18.2 months) and other racial groups (19.4 months) (Horn et al, 2006). In some cultures, early assisted toilet training (in contrast to independent toilet training in which the child learns self-management) may be the norm, with some Asian and African-American families beginning toilet training between 1 and 3 months old. This method requires that the caregiver be highly motivated to note and respond to infant elimination cues; initially the caregiver takes responsibility for placing the child on the toilet when necessary. As the child matures, he or she takes more self-responsibility (Rugolotto et al, 2008; Sun and Rugolotto, 2004). As families from various cultural groups immigrate to the U.S., health care providers need to understand these practices and be open to developing mutually agreed-on approaches to toilet training.
If begun too early, toilet training can be very stressful, contributing to enuresis, encopresis, and refusal to toilet (Mota and Barros, 2008). Late training may also be a problem. A large study by Joinson and associates (2009) found that children who started toilet training after 24 months had more problems with incontinence than children who initiated training earlier. According to Wu (2010), however, no controlled clinical trials support the hypothesis that late toilet training contributes to incontinence.
Children are typically trained first for nocturnal bowel control, then daytime bowel control, daytime bladder control, and finally nocturnal bladder control. Average times for being fully trained are around 3 to 4 years old, with a normal age variation of up to a year for individual children. In a population of U.S. Caucasian children, the average ages for girls and boys to accomplish other tasks of toilet training were as follows (Schum et al, 2002):
• Showing an interest in using the toilet: girls, 24 months; boys, 26 months
• Telling parents of their need to use the toilet: girls, 26 months; boys, 29 months
• Staying dry for at least 2 hours: girls, 26 months; boys, 29 months
• Staying dry during the day: girls, 32.5 months; boys, 35 months
There is little evidence regarding which toilet training strategy (e.g., early assisted; Brazelton’s child-oriented approach [Brazelton and Sparrow, 2004]; operant conditioning such as Azrin and Foxx’s Toilet Training in Less Than a Day [1974]) is most effective. When children and parents are ready to begin toilet training, several management techniques can be helpful (Box 12-3). If children resist training, the effort should be put on hold for a few weeks before trying again. If toddlers seem to be toilet trained for a brief period and suddenly regress to wetting and soiling consistently, they should be placed back in diapers and the process begun again within a few weeks. It is extremely important that parents and children do not become engaged in a “battle for control” over toilet training. Ultimately it is the child’s responsibility to control bowel and urinary function, and toilet training is only one of the many tasks toddlers master on their way to independence. Parents have the responsibility to assist in the process by providing a positive environment and opportunities, teaching the techniques, and setting a positive example. It appears that a structured yet flexible approach that is responsive to the child’s cues is likely to be most successful.
BOX 12-3 Management of Toilet Training
• Keep child as clean and dry as possible:
Use training pants or underwear when child stays dry for several hours during the day; use diaper at night.• Talk to child about toilet training:
Provide opportunity for child to use toilet, especially before going out to play, going on a trip, before naps, and at bedtime; set an example with adult behavior.
• Teach child how to use toilet:
• Provide practice time for child:
• Provide a comfortable, safe-feeling environment:
• Give consistent, positive feedback:
Parents can become extremely frustrated if their expectations do not match the abilities and performance of their children, and child abuse related to toilet training may occur. Berkowitz (2000) asserts that issues around toileting are the second most prevalent factor precipitating fatal child abuse. Health care providers can play a crucial role in making the experience a positive one and preventing abuse by giving parents information about child development, techniques for managing the training process, and support and encouragement for their efforts.
Altered Patterns of Elimination
Dysfunctional Elimination Syndrome
Dysfunctional elimination syndrome (DES) is any abnormal pattern in bowel or bladder function at an age when an individual is developmentally capable of control. A number of factors contribute to DES, and the close relationship between bowel and bladder function is key to understanding this complex and varied condition; it is, in reality, a set of conditions. The child may actively try to prevent bowel movements or urination (e.g., the school-age child who has restricted access to bathroom facilities). An illness may lead to dehydration, constipation, painful bowel movements, and subsequent stool withholding by the child. Trauma or disruption of the child’s life may contribute to developmental regression, with bed-wetting or inappropriate stooling. A large longitudinal study indicates that developmental delay, difficult child temperament, and maternal depression in the first 2 years of life may contribute to problems with bladder or bowel control in the school-age child (Joinson et al, 2008). Any of these factors could lead to elimination problems.
Urgency, frequency, and incontinence are common in DES, and the child may have difficulty initiating urination or completely emptying the bladder. Persistent problems with incomplete emptying of the bladder can lead to UTI. Constipation can exacerbate bladder dysfunction by applying pressure to the bladder wall or restricting urinary flow. The child may experience stool incontinence (encopresis), with or without constipation. Elimination problems also contribute to family difficulties, bullying, social isolation, emotional problems, and antisocial behaviors in families of children with fecal soiling (Joinson et al, 2006; Kaugars et al, 2010; Lottman and Alova, 2007; van Dijk et al, 2010).
The following sections discuss bowel dysfunction (fecal incontinence [encopresis] and stool toileting refusal) and urinary dysfunction (dysfunctional voiding and enuresis) in the healthy child who has no neurological or structural defect that could cause the problem. These conditions are considered here as developmental problems of normal urinary and bowel habits, improving for most children as they mature. If assessment indicates a pathological condition may be present, further investigation and different management, including referral, are necessary.
Encopresis
Description
Encopresis is defined as fecal incontinence after an age when the child should be able to control bowel movements, usually 4 years old; fecal incontinence occurs at least once per month for at least 2 months prior to diagnosis. Primary, or continuous, encopresis is present in children who have never been toilet trained. Secondary, or discontinuous, encopresis is seen in those who were previously trained but who begin to soil. There are two subtypes of encopresis: encopresis with constipation, associated with stool retention, constipation, and incontinence overflow (functional retentive fecal incontinence); and encopresis without constipation, or functional nonretentive fecal incontinence.
In encopresis with constipation, stool retention over time leads to distention of the colon and stretching of the rectum, ineffective peristalsis, decreased sensory threshold in the rectum, and weakened rectal and sphincter muscles. Stool becomes dry, hard, and difficult to evacuate (can be impacted), and bowel movements can be painful. Soft, semiformed, or liquid stool from higher in the colon leaks around retained stool and passes uncontrollably through the rectum, causing soiling. The child is often unaware of the incontinence. Children with encopresis with constipation may either refuse or be willing to use the toilet.
Children with encopresis without constipation (functional nonretentive fecal incontinence) are not constipated, but have overflow incontinence or voluntary bowel movements in their clothing or other inappropriate places.
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