TOILET HABITS IN DRUG TREATED DOWNS:
A SURVEY ON 209 SUBJECTS.
Renato COCCHI MD, neurologist and
medical psychologist
Abstract
The records of 209 drug treated
When we observe them according to prevailing forms, toilet habits so
vary (.001): normal, from 70.81% to 87.55%; atonic constipation, from 13.40% to
3.83%; spastic constipation, from 6.22% to 3.83%; diarrhoea, from 1.91% to
0.96%; celiac disease, from 0.96% to 0.00%; mixed forms, from 6.70% to 3.83%.
The improvements in toilet habits have been related to i. The decrease
of upper respiratory tract infections, and consequent cut-down of antibiotic
therapies; ii. Motor activities' amelioration; iii. The increased intake of
diet fibres, following an increased intake of diet vegetables and fruit; iv.
The emotional threshold increase; all as effects of drug therapies in
Key
words: Down’s syndrome; drug therapy; toilet habits.
Down's
syndrome
Drug modulation of stress reactions
Mental retardation
Symptoms
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The
way usually Downs empty their bowel deserved very poor interest from
researchers. This is a singular fact, since often this function brings
recurrent troubles to the
As for
itself, the toilet habit of a person in a done moment of its biological cycle
can inform us at least on some peripheral cholinergic mechanisms.
As it
happens in all mentally retarded, Down persons show many vegetative functions
more troubled, as compared with non mentally retarded individuals. Since I
nearly always looked at toilet habits in
In 1996 I
published the first epidemiological survey on toilet habits of 492
Materials and method
I have
looked into the records of a consecutive non selected series of 548 home-reared
and home living
The
records of persons having also autism or other PDDs were not looked at. The
second illness could have added new variables the weight of which does not
actually have a proper evaluation. Of the remaining records, I singled out only
those that had toilet habit looked over both at first consultation and at a
checkup after starting drug therapy.
From
these records I collected:
- sex;
-
chromosomal diagnosis;
- age
(months) at first consultation;
- age
(months) at the last checkup;
- toilet
habits at first consultation and at the last checkup.
- length
of drug therapies (months).
On these habits
I had asked the parents, or the escort and/or the Down subject himself, if he
could answer in a precise way.
This
information had always its record in very detailed way. I believed it as a
useful tool, for example, to understand how the parasympathetic intestinal tone
was working.
Among
prescribed drugs, although individually tailored, always a benzodiazepine and
pyridoxine, often l-glutamine, often carbamazepine, quite often
tetrahydrofolates and s-adenosil-l-methionine were prescribed (Cocchi, 1993).
Collected
data had statistical evaluation by
Results.
Only
209 records, referring to 209
Tab. 1: Epidemiological
data of the sample
|
|
||
|
No. of Ss |
209 |
100.00% |
|
of them F |
91 |
93.51% |
|
M |
118 |
56.46% |
|
M/F ratio |
129.67/100 |
|
|
Chromosomal diagnosis |
|
|
|
standard trisomy 21 |
187 |
89.48% |
|
mosaicisms |
7 |
3.35% |
|
translocations |
5 |
2.39% |
|
clinical diagnosis |
10 |
4.78% |
|
Age
at 1st visit (range, as months) |
4-510 |
|
|
average +/- SD |
71.21+/-79.02 |
|
|
Age
at last ckeckup (range, as months) |
8-627 |
|
|
average +/- SD |
130.16 +/- 93.58 |
|
|
Drug
therapy length (range, as months) |
|
|
|
average +/- SD |
59.57 +/- 45.98 |
|
The
M/F ratio and the distribution of chromosomal diagnoses - after pro rate
attribution of the small group of "clinical diagnoses" - lead to maintain
this sample as a representative sample.
In
restrictive sense, this is surely true at least for the whole population of
Italian Downs.
Tab. 2. Analytic
distribution of toilet habits before and after drug therapy.
|
|
||||
|
Habit |
1st visit |
% |
Last check |
% |
|
Normal |
80 |
38.28 |
168 |
80.38 |
|
Normal, with rare atonic constipation |
23 |
11.00 |
11 |
5.26 |
|
Normal, with rare spastic constipation |
15 |
7.18 |
6 |
2.87 |
|
Normal, with rare diarrrhoeas |
23 |
11.00 |
6 |
2.87 |
|
Normal with rare atonic constipation or rare spastic
constipation |
1 |
0.48 |
0 |
0.00 |
|
Normal with rare atonic constipation or rare
diarrhoeas |
1 |
0.48 |
0 |
0.00 |
|
Normal with rare spastic constipation or rare
diarrhoeas |
5 |
2.39 |
0 |
0.00 |
|
Atonic constipation |
20 |
9.57 |
7 |
3.35 |
|
Very atonic constipation |
4 |
1.91 |
0 |
0.00 |
|
Constipation, very atonic or spastic |
1 |
0.48 |
0 |
0.00 |
|
Atonic constipation or rare diarrhoeas |
2 |
0.96 |
0 |
0.00 |
|
Constipation, atonic or spastic |
6 |
2.87 |
0 |
0.00 |
|
Constipation, atonic or spastic or rare diarrhoeas |
3 |
1.43 |
0 |
0.00 |
|
Atonic constipation, rarely spastic or rare
diarrhoeas |
1 |
0.48 |
0 |
0.00 |
|
Constipation, atonic or rarely spastic |
1 |
0.48 |
1 |
0.48 |
|
Atonic constipation or diarrhoeas |
1 |
0.48 |
0 |
0.00 |
|
Spastic constipation |
11 |
5.26 |
8 |
3.83 |
|
Very spastic constipation |
1 |
0.48 |
0 |
0.00 |
|
Spastic constipation or rare diarrhoeas |
1 |
0.48 |
0 |
0.00 |
|
Spastic constipation or diarrhoeas |
1 |
0.48 |
0 |
0.00 |
|
Diarrhoeas |
4 |
1.91 |
2 |
0.96 |
|
Celiac syndrome |
2 |
0.96 |
0 |
0.00 |
Chi Square = 102180.269 with 21 df and p < .0009
As you
can see, a significant improvement of toilet habits came out after drug therapies,
with a noticeable increase of normal habits, from 38% to 80%.
Tab.
3: Toilet habits distribution, grouped according to the prevailing habit,
before and after drug therapy.
|
|
||||
|
Prevailing habit |
1st visit |
% |
last check |
% |
|
Normal |
148 |
70.81 |
183 |
87.55 |
|
Atonic constipation |
28 |
13.40 |
8 |
3.83 |
|
Spastic constipation |
13 |
6.2 |
8 |
3.83 |
|
Diarrhoea |
4 |
1.91 |
2 |
0.96 |
|
Celiac syndrome |
2 |
0.96 |
0 |
0.0 |
|
Mixed forms |
14 |
6.70 |
8 |
3.83 |
|
Totals |
209 |
100.00 |
209 |
100.0 |
Chi Square = 20.306, with 5 df and p = .001
Although
grouped according to the prevailing habit - a rough means to describe them in
this sample - toilet habits after drug therapy results even improved in a very
significant way.
Discussion
This is the second
survey on the same topic, when the feature of the first one was a general
epidemiological survey (Cocchi, 1996)
As for
itself, the way a person empties his bowel in a particular moment of his
biological cycle could inform us at least on current working of some peripheral
cholinergic mechanisms. In other terms, as for atonic constipation or the
spastic one, we can view both as opposite states of intestinal cholinergic
functions. We think atonic constipation as a state of reduced cholinergic
activity, and spastic constipation exactly as the opposite.
Despite
my purpose of having toilets habits checked for every Down I have seen after a
drug therapy period, only 209 subjects make up this sample. Here too, the
collected data can give us a picture that adds new information on something
that the parents are concerned of. As I wrote in my previous paper, literature
gives poor support to this topic.
As for
the two cases of so diagnosed celiac syndrome, Smila & Kekkonen, 1990,
asserted a prevalence of 8 cases out of a thousand alive newborns. In our group
of drug treated Downs a very curious thing happened, and I shall refer it as
such. The so-called celiac features of toilet habits in two diagnosed Downs
disappeared, and a normal diet replaced the gluten free diet.
I hope
to come back to this topic, with which I tried to do myself acquainted by
making a review of opioids' excess theory, according to Reichelt (Cocchi,
1996). I think the two cases here reported had quite forced diagnoses of celiac
syndrome.
Being
this sample representative, I found a significant improvement after drug
therapy by considering both toilet habits fully analysed (Tab. 2) and the
survey done on groups of prevailing habit (tab. 3) As I previously wrote, in
order to explain toilet habits in non drug treated Downs, we need to see about
many factors, often common to the same age general population.
We must
remember the low physical activity, the refusal of eating raw or cooked
vegetables and fruit, the need of antibiotic therapies, the so called
psychosomatic reactions. All these factors are believed stronger in Downs, with
universal consensus for low physical activity and larger use of antibiotics.
On the
refusal of the vegetables and fruit intake, as a stress symptom named
hyponeophagia, I carried out investigations both in non-treated and in drug
treated Downs (Cocchi, 1994; 1995). A lower emotional threshold common to every
mentally retarded could determine an increase in psychosomatic reactions, even
intestinal ones. We can easily
think that the ways of emptying the bowel relate to local cholinergic activity.
The last should be low intensity in atonic constipation, and higher intensity
in spastic constipation and non-infective diarrhoea.
Drug treatment acts by decreasing
susceptibility to upper respiratory tract infections (Cocchi, 1987), by
improving motor skills (Cocchi, 1989; Cocchi and Favuto, 1993; 1995), by
broadening diet with larger eating of fibres, following more cooked and raw
vegetables, and fruit intake (Cocchi, 1995), by raising the emotional threshold
because the constant presence of a benzodiazepine among prescribed drugs
(Cocchi, 1992).
It is worthy to note that this sample
already had about 70% of nearly normal toilet habits from the records taken
during the first consultation. In the larger sample of the previous research,
which encompassed the current sample too, the same rate was about 50% (Cocchi,
1996).
This appears a contradictory fact but I
suppose there should be a plain explanation. Most parents who came back for
checkup were those who observed some improvement after 3-4 months of the low
doses drug therapy of the starting. So they reached motivation to go on. In
this way a group of more easily responders could have been singled out.
There is however a variable that deserves
a deeper investigation, and I am referring to how age acts on toilet habits in
Downs. Although I did its evaluation in the previous research (Cocchi, 1996), I
shall compare drug treated and non treated Downs only by matching same age
subjects. For this I planned a third investigation on this topic.
Conclusion
The investigation on toilet habits of
209 Downs, treated by drugs for average 6 years about, showed a significant
modification both in punctual and in prevailing habit analysis. Drug therapy
favourably acted on various factors (eg. susceptibility to upper respiratory
tract infections with need of antibiotics, reduced development of motor skills,
reduced diet choice, a low emotional threshold) which all can negatively
interfere with bowel emptying.
References
Cocchi R.: Reduction of
susceptibility to upper respiratory tract infections in Down syndrome children
following treatment with GABAergic drugs: Report of 70 cases. Int. J.
Psychosom. (Philadelphia) 1987. 34/2: 3-7.
Cocchi R.: The
anticipation of walking in drug treated infants: A controlled study. It. J.
Intellect. Impair. 1989, 2: 15-19.
Cocchi R.: Drug therapy
in Down's syndrome: A theoretical context.It. J. Intellect. Impair. 1993, 6:
143-154.
Cocchi R.: Food habits
in Downs of 10 years or more. Ital. J. Intellect. Impair. 1994, 7: 143-154.
Cocchi R.: Food habits
in drug treated Downs of 10 years or more. Ital. J. Intellect. Impair. 1995, 8:
147-161.
Cocchi R.: Toilet habits
in Downs: A survey on 492 subjects. It. J. Intellect. Impair. 1996, 9: 13-25.
Cocchi R.: On gluten
free and casein free diet in autism and the opioids' excess theory: Another perspective.
It. J. Intellect. Impair. 1996, 9: 139-152.
Cocchi R., Favuto M.:
Miglioramenti motori dopo 3-8 mesi di trattamento con farmaci, nei Down. Riv.
Ital. Disturbo Intellet. 1993, 6: 251-258.
Cocchi R., Favuto M.:
Study on bike riding in Downs aged 10 or more and treated by drug therapy. It.
J. Intellect. Impair. 1995, 8: 31-36.
Smila S., Kekkonen J.:
Coexistence of celiac disease and Down syndrome. Am. J. Ment. Retard. 1990, 95:
120-122.
Printed on It. J. Intellect. Impair. 1997,
10: 13-17.
Author's address: dr Renato COCCHI, via Rabbeno, 3
42100 Reggio Emilia
(Italy)
renatococchi@libero.it
Drug
modulation of stress reactions