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The successful management of chronic constipation in infants and children
The S u c c e s s f u l M a n a g e m e n t of Chronic Constipation in Infants and Children By Teresa Sarahan, William H. Weintraub, Arnold G. Coran, and John R. Wesley A n n Arbor, Michigan 9 During a 3 yr period, 77 patients with functional constipation and 34 patients with constipation related to organic lesions of the anorectal area were managed with a strict regimen employing the longterm use of daily enemas. Seventy-four percent of the patients with functional constipation had excellent results and the rest had good results. In children with associated anorectal anomalies, 5 2 % had excellent results, 35% had good results and only 13% had a poor result. A detailed flow chart of the workup and treatment regimen is presented. INDEX WORDS: Functional constipation; sprung's disease; imperforate anus.
Hirsch-
H R O N I C C O N S T I P A T I O N is a frequent problem encountered in childhood. Its successful management is often frustrating to the responsible physician. Although certain gastrointestinal anomalies may result in constipation, the majority of the causes are of a functional nature. The intestinal anomalies are often managed successfully with surgery. The functional cases are usually the more difficult patients to treat. Numerous regimens of management have been introduced with varying success rates. In our practice of pediatric surgery at a major referral center, we have had the opportunity to treat a large number of infants and children with chronic constipation. In order to evaluate our treatment regimen, which has evolved over the past several years, the following review was undertaken.
C
MATERIALS AND METHODS For the purposes of this study, chronic constipation was defined as a bowel frequency of less than once every two days associated with fecal incontinence for a period of no less than 3 mo. This definition eliminated a large number of other patients we have seen with s h o r ~ t e r m bowel infrequency. The consistency of the stool was not one of the criteria used for classifying the child as a chronic constipator, although this became an important factor in the subsequent management of the patient. One hundred eleven children with chronic constipation were managed by the Pediatric Surgical Service at the Mott Children's Hospital in the University of Michigan Medical Center. There were 64 males and 47 females; three were black and the remainder C a u c a s i a n . Twenty nine children (26%) were under 2 yr and all of these patients presented with a complaint of infrequent stools with or without hard bowel movements. Twenty two patients
Journal of Pediatric Surgery, Vol. 17, No. 2 (April), 1982
(20%) were 2-4 yr, and fifty two (47%) were 4-13 yr. The remaining eight children (7%) were teenagers. Encopresis (fecal incontinence) with constipation was the presenting complaint in most children over 2 years. Of the children over 2 yr, only six had constipation without concomitant soiling. The history of soiling was not always easily obtained from the parents or the child, but was usually discovered by questioning the child and parents at separate times and by direct examination of the child's clothes during the physical examination. Most patients had been placed on some type of program by their primary physician prior to being seen at our institution. The only consistent feature of the prereferral regimens was that none included enemas after the first week of therapy. These treatment plans included one or more laxatives or stool softeners, dietary changes including increased amounts of fruits and fluids, and occasional or regularly spaced suppositories. Thirty four children suffered from anorectal abnormalities such as imperforate anus and Hirschsprung's disease. The remaining 77 patients were diagnosed as having functional constipation after a thorough evaluation consisting of a careful history, a rectal examination, a barium enema, and a suction rectal biopsy. Almost all of these 77 patients experienced fecal incontinence as well as infrequent bowel movements. The general outline of our treatment regimen is depicted in Fig. | . After the diagnosis of functional constipation has been established, all patients are placed on a vigorous enema program to completely cleanse the colon of the impacted stool. On the first day, one or two adult sized prepackaged oil retention enemas are sometimes used to soften the hard stool in the distal colon. Then tap water enemas (20 c c / k g of body weight) are administered on a daily basis, it generally takes approximately 7 days to completely cleanse the colon and rectum and to eliminate fecal soiling. Colace at a dose of 5 to 10 m g / k g / d a y is begun and continued throughout the treatment course. If the colace is unpalatable to the child, then mineral oil at a dose of 10 to 30 cc, one to three times a day is also satisfactory. In addition, bran cereal is encouraged at breakfast time and may sometimes even replace the stool softeners. Each morning after breakfast, the child is asked to sit on the toilet for five minutes without parental pressure in an attempt to move his bowels. After sitting on the toilet, the
From the Section o f Pediatric Surgery, University o f Michigan Medical Center, Molt Children's Hospital, Ann Arbor, Mich. Address reprint requests to Arnold G. Coran, M.D. Head, Section o f Pediatric Surgery F7516 Mott Children's Hospital Ann Arbor, Mich. 48109. 9 1982 by Grune & Stratton, Inc. 0022-3,168/82/1702-0012501.00/0
171
SARAHAN ET AL.
172
THE WORK-UP OF A CHILD WITH CHRONIC CONSTIPATION
................ l lF / t
L
] .................
[.j/
\
HIIRSCHSPRUNG'S DISEAI~E
. . . . ~RY
/
................
~
FUNCTIONAL CONSTIPATION
'3}'~::"w::':5:12: aft.'::'h~inules r1~; e IOi O~toilel :f:/:
/
.....
l ..... 21Redu~ene~ to QODif chin ~ Ior~,ef has f~l ~Hin~
i
RELAPSE
, 2) e !m!n~!e enemato q 3 daysand~e~tuaJJ~
Fig, 1. This s c h e m a t i c describes t h e s e q u e n c e of steps t a k e n to e v a l u a t e and m a n a g e t h e child w i t h chronic constipation and fecal soiling.
child is given an appropriate sized tap water enema (2(1 cc/kg) and is allowed to evacuate it as the urge to defecate is felt. This regimen is continued unaltered for I mo, at which point the child returns for an office visit. At this and subsequent monthly visits, enemas are gradually reduced to every other day, to every third day, to twice a week, and tinally they are eliminated, tlowever, the child sits on the toilet each day after breakfast whether or not an enema is administered. In addition, if the child has a spontaneous bowel movement on the toilet after breakfast, the next enema is eliminated. Bowel movements at other times of the day are considered encouraging, but arc not sulticient to stop the enema for that day. Children under 2 yr usually require only stool softeners after an initial short period of cleansing enemas since children of this age without anorectal abnormalities appear to respond to therapy much more quickly than do older patients. RESULTS
A t the time of last followup, each child was r a n k e d according to his response to the regimen. A n excellent result is defined as d i s a p p e a r a n c e of fecal soiling and spontaneous bowel movements on a r e g u l a r basis without enemas or suppositories; a stool softener m a y be required occasionally. A good result consists of m i n i m a l fecal staining (less than two times a month) and a relatively n o r m a l bowel p a t t e r n with e n e m a s b e i n g required less than twice a week. Also, children m u s t show evidence of a return to a n o r m a l lifestyle for their age. A poor result was defined as one in which the chUd continued to soil his
clothes, a n d / o r to require e n e m a s three or m o r e times a week. O f the 77 children with functional constipation, evaluation by means of multiple followup visits as well as by phone interviews with the parents was possible in all but four patients. A m o n g these, 73 patients, 54 (74%) had an excellent result while 19 (26%) had a good result. A l t h o u g h two teenagers r e m a i n e d in the poor c a t e g o r y for 2 yr, at the end of 3 yr, no child was classified as having a poor result. All of these children had essentially ceased soiling their clothes at the time of the first followup visit, one mo after initiation of t h e r a p y , in this group, there were 16 patients under two years of age; all of these returned to a normal stooling pattern. T h i r t y four patients had known physical a b n o r m a l i t i e s that required some type of surgical procedure in the anorectal area. Twenty six patients had i m p e r f o r a t e anus, three had severe spinal a b n o r m a l i t i e s , three had H i r s c h s p r u n g ' s disease, and two had tumors in the presacral space. T h e surgical procedures needed included p u l l - t h r o u g h s , anoplasties, and dilatations, the majority of which were p e r f o r m e d at other medical facilities prior to referral to us. Fifty two percent of these children experienced an excellent result, thirty live percent had a good result, and thirteen percent required e n e m a s on a regular basis and were ranked as having a poor result.
DISCUSSION
The present series consists of patients initially m a n a g e d by a p r i m a r y physician unsuccessfully and subsequently referred to our institution. Obviously, therefore, this group of children does not represent the routine case of constipation that is usually successfully m a n a g e d by the prim a r y physician who sees the patient initially. A variety of regimens were tried unsuccessfully in almost all of our patients prior to referral. O u r use of r e g u l a r enemas over a period of weeks to months a p p e a r s to be the m a j o r difference between our p r o g r a m and the ones previously used. A l t h o u g h an e n e m a m a y be considered a form of p u n i s h m e n t to a constipated child, all authors a g r e e t h a t n o regimen will work unless the colon is initially cleaned out. I-6 Occasionally a child in whom the regimen fails to completely
MANAGEMENT OF CONSTIPATION IN CHILDREN
173
evacuate the bowel after 2 wk is admitted to the hospital to obtain a more complete bowel clean out. Perhaps the most significant problem with programs that do not employ the l o n g - t e r m use of enemas is that the child is at risk of becoming reimpacted if the treatment is not completely successful. The main advantage of the enema, then, is that constipation is prevented whether or not the child is responding to the regularizing aspect of the regimen. The psychological and emotional t r a u m a of an enema has been emphasized by several authors) '2'7 M a n y psychologists have argued that the child views the enema as punishment for not moving his bowels. 6 T h e y feel that modern psychological technique advocates an award system for good behavior rather than punishment for bad behavior. Nevertheless, we did not encounter any serious objections to the enema p r o g r a m by the patients or families in our series. In fact, because the enema protocol almost immediately stops fecal soiling, there is a major psychological boost which occurs very early and is sustained. This positive psychological step invariably encourages the family and the child to continue the regimen since the single most distressing feature of constipation, namely soiling, has been eliminated. Children under two without anorectal abnormalities respond quickly to the stool softeners and end up with an excellent result, usually in less than a month. The specific temporal sequence of breakfast, followed by sitting on the toilet, followed by an enema is intended to take advantage of and to stimulate the normal gastrocolic reflex. 8 For this reason, the parents are encouraged to follow the protocol precisely and not to vary the pattern even during times of vacation. If the child has a bowel movement while sitting on the toilet fol-
lowing breakfast, the enema for that day is omitted. In milder cases, the enemas can usually be stopped after 1-2 mo, at which point the stool softeners are also tapered. In more severe situations, the treatment period required m a y be considerably longer. T e m p o r a r y failures and setbacks do occur and seem to be closely related to deviation from the program. Although enema administration in the afternoon or evening m a y be more convenient for some families, this approach does not work as well as a regular morning cycle. Apparently the gastrocolic reflex is stronger after an overnight fast. Relapses tend to be more c o m m o n when the family goes on vacation or when the regimen is not strictly followed for any other reason. All of these temporary setbacks are reversed when the child is restarted on the standard protocol. Children with anorectal anomalies also do well with this approach. Only four (13%) of these children had a poor result and required an altering of their lifestyle because of soiling and constipation. All four of these patients were males who underwent surgery for high imperforate anus. The overall results in this group of children with associated anomalies are encouraging since they are comparable to other series of patients with or without organic diseases treated with more conventional techniques. 2'9-13 The volume of enema fluid administered (20 c c / k g ) is based on data from this institution indicating that the volume of the colon can be calculated by the equation V = 233 + (83.87 x age in years). ~4 Using the average weight versus age nomogram, one can calculate the colonic volume at approximately 30 c c / k g of body weight; the enemas we administered are about two-thirds of the predicted colonic capacity.
REFERENCES
1. Clayden GS, Lawson JO: Investigation and management of long-standing chronic constipation in childhood. Arch Dis Child 51:918-923, 1976 2. Levine M: Children with encopresis: A descriptive analysis. Pediat 56:412-416, September, 1975 3. Levine M, Bakow H: Children with encopresis: A study of treatment outcomes. Pediat 58:845-852, 1976 4. McElwain JW, Alexander RM, MacLean MD: Management of functional constipation in infants and children. Med Times 97:174 176, May, 1969 5. Schnaufer I, Mahesh Kumar, White J J: Differentiation and management of incontinence and constipation problems in children. Surg Clin NAmer 50:895 905, August, 1970
6. Silber DL: Encopresis--Discussion of etiology and management. Clin Ped 8:225-231, April, 1969 7. Young GC: The treatment of childhood encopresis by conditioned gastroileal reflex training. Behav Rsch Ther (11):499-503, March, 1973 8. Davidson M, Kugler MM, Baver CH: Diagnosis and management in children with severe and protrated constipation and obstipation. J Pediat 62:261~275, 1963 9. Cywers S, Cremin BJ, Louw JH: Assessment of continence after treatment for anorectal agenesis: A clinical and radiologic correlation. J Ped Surg 6:132-137, April, 1973
174
10. Daum R, Hecker WC, Hissen W: The problem of continence following pediatric operations in the anal and rectal area. Amer J Proc 21:352 359, 1970 11. Shandling B, Desjardins JG: Anal myomectomy for constipation. J Ped Surg 4:115 118, 1969 12. Nixon HH: The use of lopermide to regulate peristal-
SARAHAN ET AL.
sis and improve bowel control: A preliminary report. J Ped Surg 13:87-88, 1978 13. Taylor I, Duthie HL, Zachary RB: Anal continence following surgery for imperforate anus. J Ped Surg 8:497503, 1973 14. Hernandez RJ, Gutowski D, Guide KE: Capacity of the colon in children. Am J of Roentg. (in press)
Hirsch-
H R O N I C C O N S T I P A T I O N is a frequent problem encountered in childhood. Its successful management is often frustrating to the responsible physician. Although certain gastrointestinal anomalies may result in constipation, the majority of the causes are of a functional nature. The intestinal anomalies are often managed successfully with surgery. The functional cases are usually the more difficult patients to treat. Numerous regimens of management have been introduced with varying success rates. In our practice of pediatric surgery at a major referral center, we have had the opportunity to treat a large number of infants and children with chronic constipation. In order to evaluate our treatment regimen, which has evolved over the past several years, the following review was undertaken.
C
MATERIALS AND METHODS For the purposes of this study, chronic constipation was defined as a bowel frequency of less than once every two days associated with fecal incontinence for a period of no less than 3 mo. This definition eliminated a large number of other patients we have seen with s h o r ~ t e r m bowel infrequency. The consistency of the stool was not one of the criteria used for classifying the child as a chronic constipator, although this became an important factor in the subsequent management of the patient. One hundred eleven children with chronic constipation were managed by the Pediatric Surgical Service at the Mott Children's Hospital in the University of Michigan Medical Center. There were 64 males and 47 females; three were black and the remainder C a u c a s i a n . Twenty nine children (26%) were under 2 yr and all of these patients presented with a complaint of infrequent stools with or without hard bowel movements. Twenty two patients
Journal of Pediatric Surgery, Vol. 17, No. 2 (April), 1982
(20%) were 2-4 yr, and fifty two (47%) were 4-13 yr. The remaining eight children (7%) were teenagers. Encopresis (fecal incontinence) with constipation was the presenting complaint in most children over 2 years. Of the children over 2 yr, only six had constipation without concomitant soiling. The history of soiling was not always easily obtained from the parents or the child, but was usually discovered by questioning the child and parents at separate times and by direct examination of the child's clothes during the physical examination. Most patients had been placed on some type of program by their primary physician prior to being seen at our institution. The only consistent feature of the prereferral regimens was that none included enemas after the first week of therapy. These treatment plans included one or more laxatives or stool softeners, dietary changes including increased amounts of fruits and fluids, and occasional or regularly spaced suppositories. Thirty four children suffered from anorectal abnormalities such as imperforate anus and Hirschsprung's disease. The remaining 77 patients were diagnosed as having functional constipation after a thorough evaluation consisting of a careful history, a rectal examination, a barium enema, and a suction rectal biopsy. Almost all of these 77 patients experienced fecal incontinence as well as infrequent bowel movements. The general outline of our treatment regimen is depicted in Fig. | . After the diagnosis of functional constipation has been established, all patients are placed on a vigorous enema program to completely cleanse the colon of the impacted stool. On the first day, one or two adult sized prepackaged oil retention enemas are sometimes used to soften the hard stool in the distal colon. Then tap water enemas (20 c c / k g of body weight) are administered on a daily basis, it generally takes approximately 7 days to completely cleanse the colon and rectum and to eliminate fecal soiling. Colace at a dose of 5 to 10 m g / k g / d a y is begun and continued throughout the treatment course. If the colace is unpalatable to the child, then mineral oil at a dose of 10 to 30 cc, one to three times a day is also satisfactory. In addition, bran cereal is encouraged at breakfast time and may sometimes even replace the stool softeners. Each morning after breakfast, the child is asked to sit on the toilet for five minutes without parental pressure in an attempt to move his bowels. After sitting on the toilet, the
From the Section o f Pediatric Surgery, University o f Michigan Medical Center, Molt Children's Hospital, Ann Arbor, Mich. Address reprint requests to Arnold G. Coran, M.D. Head, Section o f Pediatric Surgery F7516 Mott Children's Hospital Ann Arbor, Mich. 48109. 9 1982 by Grune & Stratton, Inc. 0022-3,168/82/1702-0012501.00/0
171
SARAHAN ET AL.
172
THE WORK-UP OF A CHILD WITH CHRONIC CONSTIPATION
................ l lF / t
L
] .................
[.j/
\
HIIRSCHSPRUNG'S DISEAI~E
. . . . ~RY
/
................
~
FUNCTIONAL CONSTIPATION
'3}'~::"w::':5:12: aft.'::'h~inules r1~; e IOi O~toilel :f:/:
/
.....
l ..... 21Redu~ene~ to QODif chin ~ Ior~,ef has f~l ~Hin~
i
RELAPSE
, 2) e !m!n~!e enemato q 3 daysand~e~tuaJJ~
Fig, 1. This s c h e m a t i c describes t h e s e q u e n c e of steps t a k e n to e v a l u a t e and m a n a g e t h e child w i t h chronic constipation and fecal soiling.
child is given an appropriate sized tap water enema (2(1 cc/kg) and is allowed to evacuate it as the urge to defecate is felt. This regimen is continued unaltered for I mo, at which point the child returns for an office visit. At this and subsequent monthly visits, enemas are gradually reduced to every other day, to every third day, to twice a week, and tinally they are eliminated, tlowever, the child sits on the toilet each day after breakfast whether or not an enema is administered. In addition, if the child has a spontaneous bowel movement on the toilet after breakfast, the next enema is eliminated. Bowel movements at other times of the day are considered encouraging, but arc not sulticient to stop the enema for that day. Children under 2 yr usually require only stool softeners after an initial short period of cleansing enemas since children of this age without anorectal abnormalities appear to respond to therapy much more quickly than do older patients. RESULTS
A t the time of last followup, each child was r a n k e d according to his response to the regimen. A n excellent result is defined as d i s a p p e a r a n c e of fecal soiling and spontaneous bowel movements on a r e g u l a r basis without enemas or suppositories; a stool softener m a y be required occasionally. A good result consists of m i n i m a l fecal staining (less than two times a month) and a relatively n o r m a l bowel p a t t e r n with e n e m a s b e i n g required less than twice a week. Also, children m u s t show evidence of a return to a n o r m a l lifestyle for their age. A poor result was defined as one in which the chUd continued to soil his
clothes, a n d / o r to require e n e m a s three or m o r e times a week. O f the 77 children with functional constipation, evaluation by means of multiple followup visits as well as by phone interviews with the parents was possible in all but four patients. A m o n g these, 73 patients, 54 (74%) had an excellent result while 19 (26%) had a good result. A l t h o u g h two teenagers r e m a i n e d in the poor c a t e g o r y for 2 yr, at the end of 3 yr, no child was classified as having a poor result. All of these children had essentially ceased soiling their clothes at the time of the first followup visit, one mo after initiation of t h e r a p y , in this group, there were 16 patients under two years of age; all of these returned to a normal stooling pattern. T h i r t y four patients had known physical a b n o r m a l i t i e s that required some type of surgical procedure in the anorectal area. Twenty six patients had i m p e r f o r a t e anus, three had severe spinal a b n o r m a l i t i e s , three had H i r s c h s p r u n g ' s disease, and two had tumors in the presacral space. T h e surgical procedures needed included p u l l - t h r o u g h s , anoplasties, and dilatations, the majority of which were p e r f o r m e d at other medical facilities prior to referral to us. Fifty two percent of these children experienced an excellent result, thirty live percent had a good result, and thirteen percent required e n e m a s on a regular basis and were ranked as having a poor result.
DISCUSSION
The present series consists of patients initially m a n a g e d by a p r i m a r y physician unsuccessfully and subsequently referred to our institution. Obviously, therefore, this group of children does not represent the routine case of constipation that is usually successfully m a n a g e d by the prim a r y physician who sees the patient initially. A variety of regimens were tried unsuccessfully in almost all of our patients prior to referral. O u r use of r e g u l a r enemas over a period of weeks to months a p p e a r s to be the m a j o r difference between our p r o g r a m and the ones previously used. A l t h o u g h an e n e m a m a y be considered a form of p u n i s h m e n t to a constipated child, all authors a g r e e t h a t n o regimen will work unless the colon is initially cleaned out. I-6 Occasionally a child in whom the regimen fails to completely
MANAGEMENT OF CONSTIPATION IN CHILDREN
173
evacuate the bowel after 2 wk is admitted to the hospital to obtain a more complete bowel clean out. Perhaps the most significant problem with programs that do not employ the l o n g - t e r m use of enemas is that the child is at risk of becoming reimpacted if the treatment is not completely successful. The main advantage of the enema, then, is that constipation is prevented whether or not the child is responding to the regularizing aspect of the regimen. The psychological and emotional t r a u m a of an enema has been emphasized by several authors) '2'7 M a n y psychologists have argued that the child views the enema as punishment for not moving his bowels. 6 T h e y feel that modern psychological technique advocates an award system for good behavior rather than punishment for bad behavior. Nevertheless, we did not encounter any serious objections to the enema p r o g r a m by the patients or families in our series. In fact, because the enema protocol almost immediately stops fecal soiling, there is a major psychological boost which occurs very early and is sustained. This positive psychological step invariably encourages the family and the child to continue the regimen since the single most distressing feature of constipation, namely soiling, has been eliminated. Children under two without anorectal abnormalities respond quickly to the stool softeners and end up with an excellent result, usually in less than a month. The specific temporal sequence of breakfast, followed by sitting on the toilet, followed by an enema is intended to take advantage of and to stimulate the normal gastrocolic reflex. 8 For this reason, the parents are encouraged to follow the protocol precisely and not to vary the pattern even during times of vacation. If the child has a bowel movement while sitting on the toilet fol-
lowing breakfast, the enema for that day is omitted. In milder cases, the enemas can usually be stopped after 1-2 mo, at which point the stool softeners are also tapered. In more severe situations, the treatment period required m a y be considerably longer. T e m p o r a r y failures and setbacks do occur and seem to be closely related to deviation from the program. Although enema administration in the afternoon or evening m a y be more convenient for some families, this approach does not work as well as a regular morning cycle. Apparently the gastrocolic reflex is stronger after an overnight fast. Relapses tend to be more c o m m o n when the family goes on vacation or when the regimen is not strictly followed for any other reason. All of these temporary setbacks are reversed when the child is restarted on the standard protocol. Children with anorectal anomalies also do well with this approach. Only four (13%) of these children had a poor result and required an altering of their lifestyle because of soiling and constipation. All four of these patients were males who underwent surgery for high imperforate anus. The overall results in this group of children with associated anomalies are encouraging since they are comparable to other series of patients with or without organic diseases treated with more conventional techniques. 2'9-13 The volume of enema fluid administered (20 c c / k g ) is based on data from this institution indicating that the volume of the colon can be calculated by the equation V = 233 + (83.87 x age in years). ~4 Using the average weight versus age nomogram, one can calculate the colonic volume at approximately 30 c c / k g of body weight; the enemas we administered are about two-thirds of the predicted colonic capacity.
REFERENCES
1. Clayden GS, Lawson JO: Investigation and management of long-standing chronic constipation in childhood. Arch Dis Child 51:918-923, 1976 2. Levine M: Children with encopresis: A descriptive analysis. Pediat 56:412-416, September, 1975 3. Levine M, Bakow H: Children with encopresis: A study of treatment outcomes. Pediat 58:845-852, 1976 4. McElwain JW, Alexander RM, MacLean MD: Management of functional constipation in infants and children. Med Times 97:174 176, May, 1969 5. Schnaufer I, Mahesh Kumar, White J J: Differentiation and management of incontinence and constipation problems in children. Surg Clin NAmer 50:895 905, August, 1970
6. Silber DL: Encopresis--Discussion of etiology and management. Clin Ped 8:225-231, April, 1969 7. Young GC: The treatment of childhood encopresis by conditioned gastroileal reflex training. Behav Rsch Ther (11):499-503, March, 1973 8. Davidson M, Kugler MM, Baver CH: Diagnosis and management in children with severe and protrated constipation and obstipation. J Pediat 62:261~275, 1963 9. Cywers S, Cremin BJ, Louw JH: Assessment of continence after treatment for anorectal agenesis: A clinical and radiologic correlation. J Ped Surg 6:132-137, April, 1973
174
10. Daum R, Hecker WC, Hissen W: The problem of continence following pediatric operations in the anal and rectal area. Amer J Proc 21:352 359, 1970 11. Shandling B, Desjardins JG: Anal myomectomy for constipation. J Ped Surg 4:115 118, 1969 12. Nixon HH: The use of lopermide to regulate peristal-
SARAHAN ET AL.
sis and improve bowel control: A preliminary report. J Ped Surg 13:87-88, 1978 13. Taylor I, Duthie HL, Zachary RB: Anal continence following surgery for imperforate anus. J Ped Surg 8:497503, 1973 14. Hernandez RJ, Gutowski D, Guide KE: Capacity of the colon in children. Am J of Roentg. (in press)