As usual, there was much to learn from the formal presentations, but I am always fascinated by what I learn between and after sessions in informal conversations.  Dr. McCallum, when I sat next to him at dinner the first evening, opened with, “Did you know that the colon “wakes up” about a half-hour before you do in the morning”!!!  That blew me away—of course, the “Gastrocolic” reflex we are all so aware of on awakening in the morning, if we choose to pay attention to it and not suppress it!  I enjoyed blowing him away with my observations on conditioning, the bedwetting alarm, and my ideas for using “bowel alarms” (suppositories and enemas) to overcome encopresis.  There is so much excitement at these meetings with these exchanges.  Dr. McCallum invited me to a couple of upcoming GI motility conferences.

In many respects this was a cross-disciplinary conference mainly represented by a preponderance of Pediatric Gastroenterologists (MD’s) and a small number of Psychologists (PhD’s).  Many nurses were also present and much appreciated.  A general approach and definition for FGIDs is to use symptom descriptions and to exclude medical causes resulting in diagnoses for functional disorders.  Functional disorders are functions of the body that are problematic, but within the range of normal bodily functions, e.g., shivering in the cold, muscle cramps, etc.  These disorders are certainly mediated by bodily processes (hormones, neural transmissions, brain activity), but all are subject to cognitive, social, developmental, environmental, and learning influences.  There was an appeal toward understanding that all of these factors are a part of our “material” universe and capable of scientific analysis.  Treatments may derive from medications, surgery, behavioral, and social interventions.  Dr. Hyman acknowledged that many physicians (and parents) have trouble with this view noting that it is popular to view a patient with a disease process as a “good patient” and to become frustrated and irritated where you do not have some pathological agent, metabolic disorder, or structural defect to diagnose and attack.  Parents and physicians then may become doomed by an ongoing repetitive search for purely biological causes and more frustration.  The participants in this meeting have worked toward “bridging” the contradictions that come from their largely unitary and separate professional traditional training programs.  Dr. Hyman is a very broad-minded, gentle person with a great deal of empathy for parents.  He appreciates my profession and h e has always been kind towards me though our approaches to encopresis do differ.  He is well aware of my treatment protocol as he read the Clean Kid Manual on his flight home from the last IFFGD conference.

Many syndromes and processes were discussed which are not likely to be of much practical interest to the parents of children with encopresis who visit this site.  I must say I enjoyed the exposure to the variety of areas, which were covered.  I will just list some areas to give you a flavor:  I nflammatory and neuronal factors affecting motility of the stomach and upper GI tract; sensory sensitivity to balloon distension in the stomach and rectum; “Bellyaches”; chronic vomiting; rumination; cyclical vomiting syndrome and its relationship to migraines in children; and preliminary validation studies on the Rome II criteria. 

One special diagnostic technique for assessing motility throughout the colon appears to be rapidly coming into its own, which could be relevant to encopresis, is colon manometry. This involves the insertion of a "motility tube" or long baloon along the entire length of the colon.  Observations on pressure changes at eight points may last from 90 minutes to as long as eight hours.  Very few centers currently have this capacity.  A Fact Sheet on this approach can be obtained from the IFFGD at www.iffgd.org. The technique was reported on at this conference by Carl DiLorenzo from the University of Pittsburgh Medical School Children's Hospital.  He authored the IFFGD Fact Sheet.  Lest the reader jump on this technique though, another IFFGD Fact Sheet places a valuable perspective on its application.  Dr. Jose Cocjin from the University of Kansas Medical School's Department of Pediatric Gastroenterology asks in the title, "Do we need Colonic Manometry to Diagnose Functional Fecal Retention"?  By and large he concludes that, "A detailed history and thorough physical examination can differentiate functional fecal retention from disease in most cases".  He concludes that, "Colonic manometry may be the 'last stop' for patients to distinguish colonic health from disease".

 Samuel Nurko, MD, from the Gastrointestinal Motility Unit of the Children’s Hospital in Boston was the only presenter who specifically addressed Childhood Defecation Disorders.  He noted that 5-10 percent of school age children have constipation, but this is not necessarily accompanied by encopresis.  I know I had two of my own children who were terrible toilet cloggers!  Neither ever soiled.  One, at 22 years of age, I took to an ER one evening when he had terrible stomach cramps only to discover that he was “backed up”.  I think my son started listening to me at about that point!  The tendency for constipation peaks at the time of toilet training, which makes good sense to me because of the specific and stressful demands made of the child at that time.  At the extreme you can bet a "backing up" of the stool, which is sometimes referred to as "stool hoarding" or a "megacolon". Mega comes from the Greek for "giant", recall that the atomic or hydrogen bomb's explosive power is described in megatons! Dr. Nurko noted that 3 percent of visits to a Pediatrician are concerned with constipation as contrasted to 25 percent of visits to a Pediatric Gastroenterologist (PedGI).  Clearly, in the medical world, the PedGI is the “go to” expert.  I’m sure behavioral psychologists run a very distant fourth or whatever in treating encopresis.  I know of no statistics for this.  One reason I started to offer my approach more broadly on the internet was because I had felt very underutilized in my office practice for the highly effective protocol which I had developed in the early 1980s.

Dr. Nurko, along with other PedGIs at this conference that I had incidental conversations with, remain very fixated on the oral laxative and/or stool softener approach for overflow or retentive encopresis.  Almost all noted that children would resist a bottoms-up approach.  This seems to make them “bail out” on using suppositories or enemas in any planned ongoing treatment protocol.  Perhaps this would be different if he or his profession had a more proven alternative available.  To be fair, my approach is not "proven" in the court of scientific evidence because of a lack of comparative treatment studies.  I hope that someone will pick up on this.  I am willing to assist anyone, but I cannot affort to finance such research at this time.   Dr. Nurko participated on a sub-committee establishing Clinical Guidelines for the North American Society for Pediatric Gastroenterology and Nutrition.  Their recommendations left open the choice between using rectal or oral (or both) for just the initial clean out to a joint decision by the physician and the parents.  He said that he liked Miralax as a stool softener abetting successful elimination because kids don’t fight it.  Dr. Nurko even announced that he has a toilet training school.  He noted the use of diaries, stickers, and positive reinforcement approaches, which I largely find unnecessary, as there are so many inherent awards experienced with the natural relief resulting from successful daily evacuations with my more focused and timely approach.  He reported that 50% of patients recover in one year and 65-70 percent in 2 years with his more traditional approach.

Dr. Nurko and other physicians were quite sensitive to the fears that parents have over their children’s constipation and clearly seek to frequently reassure them.  However, without more definitive and earlier results I find those parents who come to my site just become more frustrated with their PedGIs reassurances in the absence of results.  My sample of parents may be poorly representative of the majority of patients who may well persist with the reassurances of their PedGIs.

On several occasions I had conversations with the parents present.  In the main, most had children with very serious and long-lasting conditions requiring surgical interventions and medication.  These often included “pseudo obstruction” which involves a true motility disorder, which would include Hirschsprung’s Disease.  There were many parents who were very grateful to their PedGIs.  The mutual reinforcement cycle between parents and doctors was clearly obvious to me for these very serious disorders.  I did not encounter any parents with retentive encopresis of a largely functional nature.  Maybe this is why encopretic children with a functional disorder are not being properly addressed despite Dr. Hyman’s dedicated and admirable efforts to address all functional issues.

This was an exciting conference and it will be on my must attend list whenever it is scheduled.  Keep an eye on my Clean Kid Treatment page for any future announcements!  RWC