TOILET HABITS IN DOWNS:
A SURVEY ON 492 SUBJECTS.
Renato COCCHI,
neurologist and medical psychologist
Summary
The records
of an unselected consecutive series of 530 Down Ss, all seen by the author,
were examined as for toilet habits, as checked at first consultation. The
records of thirty-eight psychotic Downs were discarded because possible
interferences of the superimposed psychosis.
The
remaning 492 showed their year of birth ranging from 1944 to 1995 and were so
distributed: 286 M + 206 F; M/F ratio = 139/100; chromosomal anomalies: pure
trisomy 21 = 90.04%; mosaicism = 3.05% , translocations = 3.25%, unknown = 3.66%.
The sample was split up into 12 age subsamples from 4-6 months to 181 months
and more.
The
results shows that normal or nearly normal toilet habits range from about 40%
to 80%; average more than 50% have scarce troubles or no one in this respect.
Atonic or mainly atonic constipation is the more frequent toilet trouble and
could be found from about 7% to about 23%, and averages about 13%. Spastic or
mainly spastic constipation has 30% as its main value in the 49-60 age group
but is average about 9%.
Many age groups do not have Ss with
frequent diarrheas as prevalent toilet habit. Diarrheas could be found in age
from 13 to 60 months and in the 109-132 months age group. When present, such a
trouble averages about 3.5%.
Lastly, mixed forms average 3%, of which
the more frequent is alternation of atonic or spastic constipation, followed by
alternation of spastic constipation and diarrheas.
Key words: Down's syndrome; toilet's
habits; age; epidemiology; survey.
Symptoms
Down's syndrome
Mental retardation
Home Page
The way usually Downs empty their bowels do not seem
to have got any interest from researchers. This fact appears singular since
often such habits bring recurrent troubles for the subjects themselves and the
parents.
Perhaps a poor understanding of the link
between these habits and the general well-being is the reason of it. In itself,
the way a person evacuates in a moment of its biological cycle can inform us at
least about peripheral cholinergic mechanisms. In other terms, atonic and
spastic constipation, look as opposite states of intestinal cholinergic
functions, with scarce or excess working. The anecdotal reports of the mothers
about constipation after antibiotic therapies in their children did not reach
the attention they could have deserved.
On the other hand, many of us can hardly
claim the so-called damage of the intestinal flora balance after antibiotics,
for the cause when the exit is not diarrhea.
While in general we can accept these
premises, yet these habits i n Down Ss would have had more attention. Like in
all other MR people, these persons show increased troubles in many vegetative
processes.
Having nearly always asked for information
about evacuating habits in Downs since their first consultation, I thought I
collected a large amount of data on it.
Subjects
and method.
I checked the reports of 530 Down syndrome
subjects I saw at first consultation from January 1979 to April 1966. From
these I did not look at reports of psychotic Down subjects, having thought the
dual diagnosis could be a relevant variable.
From each report I collected sex, the year
of birth, the age at first consultation, chromosomal anomaly and toilet habits.
Only when I reported these habits in first
consultation's records, they fitted for this survey. Having treated these subjects
by drugs, following checkups, usually three months later, could yet have varied
them as for this symptom.
The records report the prevalent symptom
alone (normality, atonic constipation, spastic constipation or diarrheas) or in
mixed forms.
Atonic constipation means not daily
evacuation with hard and large faeces. Spastic constipation means not daily
evacuation with faeces in small bolls, like goats do.
Mixed forms vary from mixed with a prevalent
habit to nearly same presence of two or more habits.
After a total processing of the data, the
same were singled out according to age at first consultation, from 4-6 months
to 181-510 months.
Graphics shows rate distributions by age of
the prevalent forms or true mixed forms.
Data were only processed in plain
statistics.
Results.
Only 492 reports out of 530 fitted the
criteria of this survey. The data were summarized in Table 1-14 and in Graphics
1-5.
Table 1, shows the epidemiological data of
the sample.
Tab. 1: epidemiological data of the sample.
|
No. of Ss |
492 |
100.00% |
|
of them M |
286 |
58.13% |
|
F |
206 |
41.87% |
|
M/F |
139:100 |
|
|
Birth year's range |
1944-1995 |
|
|
Chromosomal anomalies: |
|
|
|
Unknown |
18 |
3.66% |
|
Standard Trisomy 21 |
443 |
90.04% |
|
Mosaicisms |
15 |
3.05% |
|
Translocations |
16 |
3.25% |
As we can see, the ratio F/M matches
both Italian and international gender distribution and the same happens for
chromosomal anomalies, though 18 out of 492 are unknown.
In Table 2 I reported the evacuating
habits of the total sample, as I collected them during first consultations.
Tab. 2 Evacuation habits of the samples, as collected during the first consultation.
|
Habit |
No. of Ss |
% |
|
Not collected |
82 |
16.67 |
|
Celiachia |
1 |
0.20 |
|
Normal |
146 |
29.66 |
|
Normal, but dry faeces: |
10 |
2.03 |
|
Normal with rare atonic constipation |
46 |
9.35 |
|
Normal with rare spastic constipation |
36 |
7.32 |
|
Normal, with rare diarrheas |
27 |
5.49 |
|
Normal with rare atonic constipation orrare spastic constipation |
2 |
0.41 |
|
Normal with rare atonic constipation or rare darrheas |
3 |
0.61 |
|
Normal with rare spastic constipation or rare diarrheas |
6 |
1.22 |
|
Constipation, atonic |
46 |
9.35 |
|
Constipation, atonic or rare diarrheas |
5 |
1.02 |
|
Constipation, atonic or spastic |
8 |
1.63 |
|
Constipation, atonic or spastic, or rare diarrheas |
3 |
0.61 |
|
Constipation, atonic or spastic or diarrheas |
1 |
0.20 |
|
Constipation, atonic, rarely spastic or rare diarrheas |
2 |
0.41 |
|
Constipation, atonic or rarely spastic |
1 |
0.20 |
|
Atonic constipation, or diarrheas |
2 |
0.41 |
|
Constipation, spastic |
31 |
6.30 |
|
Constipation, spastic or rarely atonic |
6 |
1.22 |
|
Constipation, spastic or rare diarrheas |
9 |
1.83 |
|
Spastic constipation or diarrheas; |
2 |
0.41 |
|
Diarrheas |
10 |
2.03 |
|
Totals |
492 |
100.00 |
In 82 cases out of 492 I did not ask for
it, I cannot remember why. Probably I forgot asking this habit, although I
planned to do it. About 30% of the sample reported absolutely normal evacuating
habit at the time of their first consultation.
A small group of Down babies, aged
4-6 months, had its description in Table 3.
Tab. 3: habits of 15 Ss (7 M + 8 F) aged 4-6 months.
|
Habit |
No. of Ss |
% |
|
Not collected |
2 |
13.33 |
|
Normal |
7 |
46.66 |
|
Normal, but dry faeces |
1 |
6,67 |
|
Normal with rare spastic constipation |
1 |
6,67 |
|
Normal, with rare diarrheas |
2 |
13.33 |
|
Normal with rare atonic constipation or rare spastic constipation |
1 |
6.67 |
|
Constipation, atonic |
1 |
6.67 |
|
Totals |
15 |
100.00 |
While most of them had normal or quite normal
evacuation, we can see a case of atonic constipation.
Forty-six babies aged 7-12 months, made
the Table 4 up.
Tab. 4: habits of 46 Ss (25 M + 21 F) aged 7-12 months.
|
Habit |
No. of Ss |
% |
|
Not collected |
7 |
15.22 |
|
Normal |
17 |
36.96 |
|
Normal, but dry faeces |
1 |
2.17 |
|
Normal with rare atonic constipation |
5 |
10.85 |
|
Normal with rare spastic constipation |
4 |
8.70 |
|
Normal, with rare diarrheas |
3 |
6.52 |
|
Constipation, atonic |
3 |
6.52 |
|
Constipation, very atonic |
2 |
4.36 |
|
Constipation, atonic or rare diarrheas |
1 |
2.17 |
|
Constipation, atonic or spastic |
1 |
2.17 |
|
Constipation, atonic or spastic or diarrheas |
1 |
2.17 |
|
Constipation, spastic |
1 |
2.17 |
|
Totals |
46 |
100.0 |
Atonic or spastic constipation or mixed
forms count up 9 babies out of 42, being an actual trouble.
Table 5: Habits of 78 Ss ( 44 M + 34 F) aged 13-24
months
|
Habit |
No. of Ss |
% |
|
Not collected |
10 |
12.83 |
|
Celiachia |
1 |
1.28 |
|
Normal |
20 |
25.65 |
|
Normal, but dry faeces |
2 |
2.56 |
|
Normal with rare atonic constipation |
8 |
10.27 |
|
Normal with rare spastic constipation |
9 |
11.54 |
|
Normal, with rare diarrheas |
6 |
7.69 |
|
Normal with rare atonic constipation or rare spastic constipation |
1 |
1.28 |
|
Normal with rare spastic constipation or rare diarrheas |
1 |
1.28 |
|
|
|
|
|
Constipation, atonic or rare diarrheas |
2 |
2.56 |
|
Constipation, atonic or spastic |
2 |
2.56 |
|
Constipation, atonic or spastic, or rare diarrheas |
2 |
2.56 |
|
Constipation, atonic, rarely spastic or rare diarrheas |
1
|
1.28
|
|
Constipation, spastic |
3 |
3.85 |
|
Constipation, spastic or rarely atonic |
2 |
2.56 |
|
Diarrheas |
2 |
2.56 |
|
Totals |
78 |
100.00 |
In Table 5, about the same rate of infants had the same troubles in their evacuating habits, as we found in 7-12 months babies. Diarrheas, as prevalent habit, started to appear in one infant.
Tab. 6: Habit of 63 Ss (34 M + 29 F) aged 25-36 months.
|
Habit |
No. of Ss |
% |
|
Not collected |
12 |
19.04 |
|
Normal |
17 |
26.97 |
|
Normal with rare atonic constipation |
8 |
12.70 |
|
Normal with rare spastic constipation |
5 |
7.94 |
|
Normal with rare spastic constipation or rare diarrheas |
1 |
1.59 |
|
Constipation, atonic |
5 |
7.94 |
|
Constipation, very atonic |
1 |
1.59 |
|
Constipation, atonic or rare diarrheas |
1 |
1.59 |
|
Constipation, atonic or spastic |
1 |
1.59 |
|
Constipation, spastic |
7 |
11.11 |
|
Diarrheas |
5 |
7.94 |
|
Totals |
63 |
100.00 |
We found evacuating troubles at least in
about 1/3 of the 3-years old infants, with the maximum presence of diarrheas, as
reported in Table 6. The increase of spastic constipation is to be pointed up,
having now the same rate of atonic constipation.
Tab. 7: Habits of 35 Ss (21 M + 14 F) aged 37-48 months.
|
Habit |
No. of Ss |
% |
|
|
Not collected |
5 |
14.28 |
|
|
Normal |
7 |
20.00 |
|
|
Normal, but dry faeces |
1 |
2.06 |
|
|
Normal with rare atonic constipation |
4 |
11.43 |
|
|
Normal with rare spastic constipation |
2 |
5.71 |
|
|
Normal, with rare diarrheas |
1 |
2.06 |
|
|
Normal with rare atonic constipation or rare diarrheas |
2 |
5.71 |
|
|
Constipation, atonic |
7 |
20.00 |
|
|
Constipation, very atonic |
1 |
2.06 |
|
|
Constipation, spastic |
4 |
11.43 |
|
|
Diarrheas |
1 |
2.06 |
|
|
Totals |
35 |
100.00 |
|
The 37-48 months' age group in Table 7
looks different, although more than 35% of the children have toilet troubles.
There is a decrease both in spastic constipation and in diarrheas.
Tab. 8: Habits of 40 Ss (24 M + 16 F)
aged 49-60 months
|
Habit |
No. of Ss |
% |
|
|
Not collected |
7 |
17.50 |
|
|
Normal |
11 |
42.50 |
|
|
Normal, but dry faeces |
1 |
2.20 |
|
|
Normal with rare atonic constipation |
3 |
7.50 |
|
|
Normal with rare spastic constipation |
3 |
7.50 |
|
|
Normal with rare spastic constipation or rare diarrheas |
1 |
2.50 |
|
|
Atonic constipation, or diarrheas |
1 |
2.50 |
|
|
Constipation, spastic |
5 |
12.50 |
|
|
Constipation, spastic or rarely atonic |
2 |
5.00 |
|
|
Constipation, spastic or rare diarrheas |
5 |
12.50 |
|
|
Spastic constipation or diarrheas |
1 |
2.50 |
|
|
Diarrheas |
1 |
2.50 |
|
|
Totals |
40 |
100.00 |
|
Maximum of spastic constipations
was the prominent feature of toilet troubles in 49-60-months children, as the Table
8 shows. Thirty percent of this age group complained of them, while the total
rate of children with toilet troubles did not vary.
Tab. 9: Habits of 52 Ss (34 M + 18 F) aged 61-84 months
|
Habit |
No. of Ss |
% |
|
|
Not collected |
7 |
13.46 |
|
|
Normal |
16 |
30.78 |
|
|
Normal, but dry faeces |
2 |
3.85 |
|
|
Normal with rare atonic constipation |
7 |
13.46 |
|
|
Normal with rare spastic constipation |
3 |
5.77 |
|
|
Normal, with rare diarrheas |
5 |
9.62 |
|
|
Constipation, atonic |
4 |
7.69 |
|
|
Constipation, atonic or spastic |
1 |
1.92 |
|
|
Constipation, atonic or rarely spastic |
1 |
1.92 |
|
|
Constipation, spastic |
3 |
5.77 |
|
|
Constipation, spastic or rarely atonic |
1 |
1.92 |
|
|
Constipation, spastic or rare diarrheas |
1 |
1.92 |
|
|
Spastic constipation or diarrheas |
1 |
1.92 |
|
|
Totals |
52 |
100.00 |
|
The 61-84 months' age range, as summed
up in Table 9, reported a coming back to about 23% of toilet troubles, with same
rates of atonic or spastic constipations.
Tab. 10: Habits of 38 Ss ( 27 M + 11 F) aged 85-108 months.
|
Habit |
No. of Ss |
% |
|
|
Not collected |
7 |
18.42 |
|
|
Normal |
16 |
42.12 |
|
|
Normal with rare atonic constipation |
3 |
7.89 |
|
|
Normal with rare spastic constipation |
1 |
2.63 |
|
|
Normal, with rare diarrheas |
2 |
5.26 |
|
|
Constipation, atonic |
4 |
10.53 |
|
|
Constipation, very atonic |
1 |
2.63 |
|
|
Constipation, atonic or spastic |
2 |
5.26 |
|
|
Constipation, atonic or spastic, or are diarrheas |
1 |
2.63 |
|
|
Constipation, spastic |
1 |
2.63 |
|
|
Totals |
38 |
100.00 |
|
According to data shown in Table 10,
children aged 65-108 months do the same rate of total toilet troubles as
previous age group did. Atonic constipation comes again at first place.
Tab. 11: Habits of 47 Ss (26 M + 21 F) aged 109-132
months
|
Habit |
No. of Ss |
% |
|
|
Not collected |
10 |
21.28 |
|
|
Normal |
14 |
29.78 |
|
|
Normal with rare atonic constipation: |
3 |
6.38 |
|
|
Normal with rare spastic constipation |
3 |
6.38 |
|
|
Normal, with rare diarrheas |
5 |
10.64 |
|
|
Normal with rare spastic constipation or rare diarrheas |
1 |
2.13 |
|
|
Constipation, atonic |
4 |
8.51 |
|
|
Constipation, atonic or spastic |
1 |
2.13 |
|
|
Constipation, spastic |
5 |
10.64 |
|
|
Diarrheas |
1 |
2.13 |
|
|
Totals |
47 |
100.00 |
|
Also the age group of children aged
109-132 months shows the same rate of toilet troubles, as summed up in Table
11. There is a slight prevalence of spastic constipation.
Tab. 12: Habits if 36 Ss
(19 M + 17 F) aged 133-156 months
|
Habit |
No. of Ss |
% |
|
|
Not collected |
7 |
19.44 |
|
|
Normal |
10 |
27.77 |
|
|
Normal, but dry faeces |
1 |
2.78 |
|
|
Normal with rare atonic constipation |
3 |
8.33 |
|
|
Normal with rare spastic constipation |
4 |
11.11 |
|
|
Normal, with rare diarrheas |
2 |
5.56 |
|
|
Constipation, atonic |
6 |
16.67 |
|
|
Constipation, very atonic |
1 |
2.78 |
|
|
Constipation, spastic or rare diarrheas |
2 |
5.56 |
|
|
Totals |
36 |
100.00 |
|
As we can see in Table 12, although the total
toilet troubles remain in the same percent rate, atonic constipation highly
prevails in the 133-156 months' age group.
Tab. 13: Habits of 15 Ss (11 M + 4 F) aged 157-180
months.
|
Habit |
No. of Ss |
% |
|
|
Not collected |
4 |
26.67 |
|
|
Normal |
2 |
13.33 |
|
|
Normal, but dry faeces |
1 |
6.67 |
|
|
Normal with rare atonic constipation |
2 |
13.33 |
|
|
Normal with rare spastic constipation |
1 |
6.67 |
|
|
Normal, with rare diarrheas |
2 |
13.33 |
|
|
Normal with rare spastic constipation or rare diarrheas |
1 |
6.67 |
|
|
Constipation, atonic |
2 |
13.33 |
|
|
Totals |
15 |
100.00 |
|
In young Downs 13-15 years old toilet
troubles had a reduced report, and only in form of atonic constipation, as
summed up in Table 13.
Tab. 14: Habits of 27 Ss (17 M + 10 F) aged 181-510
months (15;1-43;6 years)
|
Habit |
No. of Ss |
% |
|
|
Not collected |
4 |
14.82 |
|
|
Normal |
9 |
33.34 |
|
|
Normal with rare atonic constipation or rare diarrheas |
1 |
3.70 |
|
|
Normal, rare spastic constipation or rare diarrheas |
1 |
3.70 |
|
|
Constipation, atonic |
4 |
14.82 |
|
|
Constipation, very atonic |
1 |
3.70 |
|
|
Constipation, atonic or rare diarrheas |
1 |
3.70 |
|
|
Constipation, atonic or spastic, or rare diarrheas |
1 |
3.70 |
|
|
Atonic constipation, or diarrheas |
1 |
3.70 |
|
|
Constipation, spastic |
2 |
7.42 |
|
|
Constipation, spastic or rarely atonic |
1 |
3.70 |
|
|
Constipation, spastic or rare diarrheas |
1 |
3.70 |
|
|
Totals |
27 |
100.00 |
|
Table 14 encompasses a very large age
group, with prevalence of subjects referring to toilet troubles, mainly atonic
constipation.
Graphic 1 shows that normal or
nearly normal toilet habits range from about 40% to 80%; average more than 50%
have scarce troubles or no one in this respect.
Atonic or mainly atonic
constipation is the more frequent toilet trouble and can be found from about 7%
to about 23% and averages about 13%, as reported in Graphic 2.
In 49-60 months' age group none referred
atonic or mainly atonic constipation, although there are few episodic reports
of such a trouble in mixed forms.
Two age groups, 4-6 months and
167-180 months do not present spastic or mainly spastic constipation that has 30%
as its main value in the 49-60 age group. This trouble is average about 9%, as
in Graphic 3.
As for Graphic 4, many age groups do not
have frequent diarrheas as prevalent toilet habit. This can be found in age
from 13 to 60 months and in the 109-132 months age group. When present, such a
trouble averages about 3.5%.
Lastly, Graphic 5 shows mixed
forms, of which the more frequent is alternate atonic or spastic constipation,
followed by alternation of spastic constipation and diarrheas. Mixed forms does
not reach 3% average.
Discussion.
This survey presents data on 410 Down subjects
out of 492. Although I have intended to check toilet habits in all Downs who
went at consultation, I forgot to do it in about 17% of them.
In spite of all that, the data I
collected can start to frame what could usually be neglect as a coarse symptom,
not deserving any interest. I think we have to reject this trivial medical
conduct, although now toilet habits, except prolonged diarrheas, mainly belong
to the field of self-medication.
The literature gives very poor help. I
did not found any reference to these symptoms in books of Lambert e Rondal,
1979; CePiM, 1984, Rondal, 1986; Bomey, Echavidre & Patte-Malson, 1985.
Nowak, Ghishan & Schulze Delrieu, 1983; Simila & Kekkonen, 1990 wrote
about celiac disease. Williams et al., 1985, tested xylose malabsorption,
suggesting that this last could play a role in a number of the vitamin and
mineral deficits found in people with Down syndrome.
About celiac disease, of which I found
only one diagnosed case in this survey, Simila & Kekkonen, 1990 counted it
up to 8 per 1000 live-born cases. As these Authors stated, this illness could
be kept in mind when checking Downs complaining recurrent diarrheas and/or
delayed puberty.
To explain toilet habits in Down we
ought to look at many factors, often shared with the same age general
population.
We can remind the poor physical
activity, the refusal for boiled or raw vegetables and fruit, the need for
antibiotic therapies, the so-called psychosomatic reactions. All these factors
looks as more pronounced in Downs, at least as usually reported for poor
physical activity and a larger use of antibiotics. As for the refusal for
vegetables and fruit, as a symptom of stress named hyponeophagia, I checked it
both in non treated Downs and in Downs treated with drugs as antistress therapy
(Cocchi, 1994 & 1995). The low emotional threshold, a symptom common to all
mentally retarded, can get up to more psychosomatic reactions, even intestinal
too. It is likely to think that toilet habits reflect also bowel cholinergic
functions, with low working in atonic constipation and higher working in
spastic constipation and noninfective diarrheas.
Although more than average 50% of our
sample do not have evacuation difficulties, this is a poorly understood problem
and is worthy of better investigation.
I planned a next survey on toilet habits
in drug-treated Down, since drug therapies are mainly antistress therapies.
References
Bomey M.-J., Echavidre P., Patte-Malson
L.: Le Mongolisme. Au-delà de la lègende. CTNERHI, Vanves 1986.
Ce.Pi.M: Aspetti epidemiologici,
genetici, clinici, riabilitativi e sociali della Sindrome di Down. Ce.Pi:M.,
Genova, 1984
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.
Lambert J.L., Rondal J.A.: Le
Mongolisme. Mardaga, Bruxelles, 1979.
Nowak T. V., Ghishan F.K., Schulze
Delrieu K.: Celiac sprue in Down's syndrome. Consideration on a pathogenetic
link. Am. J. Gastroenterol. 1983, 78: 280-283.
Rondal J.A., Lambert J.L.: Questions et
réponses sur le mongolisme. Maloine, Paris 1982.
Smila S., Kekkonen J.: Coexistence of
celiac disease and Down syndrome. Am. J. Ment. Retard. 1990, 95: 120-122.
Williams C.A., Quinn H., Wright E.c. et
al.: Xylose absorption in Down's syndrome. J. Ment. Defic. Res. 1985,
29: 173-177.
First printed on It. J. Intellect. Impair. 1996, 9: 13-25.
Author's address : dr Renato COCCHI, via Rabbeno, 3
42100 Reggio Emilia (Italy).
renatococchi@libero.it
Symptoms
Down's syndrome
Mental retardation
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