Prevalence, Risk Factors, and Pediatrician Awareness of Infant Dyschezia in Indonesia

Functional gastrointestinal disorders (FGIDs) are common in children of all ages, including infants, and comprise of a wide range of chronic and recurrent gastrointestinal symptoms that cannot be attributed to structural or biochemical abnormalities [1]. FGIDs especially during infancy are the most common reasons for caregivers to visit health care facilities [2, 3]. Data regarding prevalence and risk factors of infant dyschezia are still lacking compared to other FGIDs.

Moreover, pediatrician awareness in Indonesia regarding the diagnosis and management of infant dyschezia also remains unknown. Inaccurate diagnosis and management of this disease may result in the expense of immense cost with barely any positive outcomes for both patients and clinicians [4]. The current Rome criteria IV defines infant dyschezia as straining and crying for at least 10 minutes before successful passage of soft stools in an infant <9 months old without any other health problems.

To date, no study has reported the prevalence and risk factors of infant dyschezia in Indonesia based on the latest Rome criteria. This study aimed to evaluate the prevalence and risk factors of infant dyschezia as well as pediatrician awareness of this disease in Jakarta, Indonesia.

The prevalence of infant dyschezia based on the result of this study was 11.8%, which was higher than that in other neighboring Asian countries. One multi-ethnic study in a well-baby clinic at Kuala Lumpur, Malaysia reported a very low prevalence of this disease, which was only 1.3% based on the Rome IV criteria [5]. Furthermore, a study based on the same criteria was conducted in Vietnam and similarly reported the low prevalence of infant dyschezia, which was only 0.9% with no discrepancy between rural and urban population [6]. However, a study by Gatcheco et al. [7] in the Philippines showed a prevalence of 16.6% among infants aged 0–6 months. These numbers are similar to that in developed countries, ranging from 2.4% to 11.6% in the US [3, 8]. The discrepancy of reported prevalence may be due to different perception of parents regarding crying and straining prior to their infant’s defecation. Another factor to be noted was the location of each study; studies conducted at non-well-baby clinics or hospitals may report higher prevalence as there was a possibility of selection bias in which mothers were more likely to report symptoms in the setting of non-well-baby health care facilities.

One multicenter cross-sectional stud by Chogle et al. [9] reported that the prevalence of infant dyschezia based on the Rome III criteria, which only included infants <6 months old, was 15%. However, when adjusted to the Rome IV criteria, which now included infants up to 9 months old, an additional 13% of those infants fulfilled the criteria for infant dyschezia [9]. This finding indicated that after age criteria was expanded from 6 to 9 months, more cases of infant dyschezia can be detected. Interestingly, our study observed a higher prevalence of infant dychezia among infants aged 7–9 months who would not have been diagnosed had Rome III criteria been used.

To date, few studies have reported the risk factors of infant dyschezia. Of the 14 risk factors evaluated in our study, three factors had a significant influence on the occurrence of infant dyschezia, including being an only-child, receiving a complementary feeding diet, and the presence of socio-emotional disorders based on BPSC.

A previous study reported that the prevalence of FGIDs in infants, based on parental reports, was higher in those who did not have any siblings [10]. Similar to the aforementioned study, this study demonstrated that being an only child in the family made infant dyschezia 5.6 times more likely to be reported compared to those with siblings (OR, 5.619; 95% CI, 2.194–14.390; p<0.001). This finding could be explained by increased attention (attention bias) towards the symptoms presented by the only child in the family [10].

Diet plays an important role on the occurrence of infant dyschezia. One study in Manila using Rome III criteria reported that participants who received a combination of breast milk and formula milk had higher risk (OR, 4.69; 95% CI, 1.96–11.24; p=0.003), and those who received only formula milk had an even higher risk (OR, 8.85; 95% CI, 4.17–19.00; p=0.020) of experiencing infant dyschezia compared to infants who received only breast milk [7]. However, our study utilized Rome IV criteria and, consequently, included 7-9-month-old infants who had received a complementary food diet. Based on our study, infants who received a complementary food had 4.2 times higher risk of experiencing infant dyschezia compared to infants who did not receive complementary foods (OR, 4.238; 95% CI, 1.902–9.443; p<0.001). Interestingly, higher prevalence of infant dyschezia was observed among infants in the 7–9 months age group compared to the other age groups, which further supported the theory that infant dyschezia is more likely to develop as infants begin to receive complementary food. The defecation process involves the coordination of pelvic muscles as well as simultaneous contraction of the abdominal muscles and relaxation of the anal sphincter [11]. When an infant is introduced to more solid food, the frequency of bowel movements and stool consistency adapts in a way that infant will defecate less often and with a thicker stool consistency. For infants who have not gotten used to the defecation process, changes in stool consistency will make them more difficult to pass the stool [11]. Thereby, based on the results of this study, we suggest the need for pediatricians to be more aware of the occurrence of infant dyschezia, especially among infants who start receiving complementary foods.

This study also observed that infants with socio-emotional disturbances were 5.6 times more likely to experience infant dyschezia (OR, 5.670; 95% CI, 2.550–12.609; p<0.001) than those without. However, this cross-sectional study cannot simply establish a causal relationship between those variables, as the relationship of socio-emotional disturbance and infant dyschezia may be bidirectional. First, the occurrence of infant dyschezia triggers discomfort for the infant and consequently socio-emotional problems arise. A study by Uzun Çiçek et al. [12] demonstrated that infants with dyschezia had a higher risk of experiencing developmental and daily routines impairments, such as weight gain, irregular sleep patterns, and dysuria than those without. Furthermore, socio-emotional impairment in infants impede the learning of defecation process, which ultimately results in infant dyschezia.

The development of social and emotional skills in infants is closely related to the parent-child relationship. A close physical and emotional bonding between infants and caregivers (usually mothers) during the first year of life will provide a sense of security while also building emotional regulation and self-control skills in infants [13]. One study compared the psychosocial state of mothers whose babies suffered from infant dyschezia and those whose infants did not. Mothers of infants with dyschezia had significantly higher Brief Symptoms Inventory scores across all nine sections (somatization, obsessive-compulsive disorder, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideas, and psychoticism) [12]. This was due to the fact that mothers of infants with dyschezia had more social and economic struggles such as lower education, employment levels and income, more children, and lack of support from their partners in taking care of them. The association of infant dyschezia and the psychosocial state of the mother can be described in two ways. First, the incidence of infant dyschezia can be influenced by the mental health of the mother; therefore, attention should be paid to the psychological state of the mother. Moreover, dyschezia in infants may lead to anxiety and other negative emotions for the mother already experiencing physical and mental stress. This happens particularly if infant dyschezia occurrs repeatedly without any improvement after various therapies attempted by the mother [12].

Based on a study by Vandenplas et al. [2] who conducted a survey on pediatric medical professionals worldwide, 69% of them were aware of infant dyschezia while the rest classified it as part of the colic spectrum or functional constipation. In our study, pediatricians were surveyed regardless of their subspecialty and 71.5% of them were able to diagnose infant dyschezia precisely. Those who had practiced >10 years were more likely to misdiagnose infant dyschezia than those who had practiced for <10 years. The Rome III criteria as a diagnostic tool for FGIDs in children and toddlers was published in 2006, while the latest Rome IV criteria was introduced in 2016. It was very likely that pediatricians who graduated from specialist education more than 10 years ago were less familiar with the changes of the latest Rome criteria for children and toddlers, especially regarding the diagnosis of infant dyschezia. Most pediatricians in our study had practiced the appropriate management of infant dyschezia as they did not perform any additional diagnostic test (79.7%) and only provided education for parents (58.5%). Precise diagnosis and treatment for infant dyschezia is crucial to avoid the expense of enormous cost with almost no positive outcome as demonstrated by Dhroove et al. [4]. A total of 28.5% of pediatricians gave pre-/probiotic therapy for infant dyschezia. Probiotic therapy of L. reuteri had been shown to have a positive effect on peristalsis in infants with chronic constipation, although there was no improvement in stool consistency and crying episodes as well as no improvement of clinical symptoms for infantile colic [14]. Currently, there is no adequate beneficial evidence of the role of pre-/probiotics for infant dychezia. Hence, further studies are needed to evaluate the role of pre-/probiotics not only for infant dyschezia but also for other FGID.

This study has some limitations First, it was a cross-sectional study. Therefore, causal effects between infant dyschezia and socio-emotional disturbances could not be determined. Second, we did not evaluate enough time frame to determine which variable occurred first in the participants. Third, participants in both studies were recruited from one area; hence, may not represent the whole population in Indonesia. Therefore, future multi-center studies, including infants from different regions of Indonesia are warranted. The strength of this study is the use of validated Rome IV questionnaire form to diagnose infant dyschezia, which effectively reduced the differences of perceptions among parents regarding this disease. Moreover, this questionnaire underwent a rigorous process of translation and testing before finally being approved by the Rome Foundation to be used in this study.

In conclusion, our study revealed that the prevalence of infant dyschezia in Jakarta, Indonesia was higher than that in other neighboring Asian countries, with the highest prevalence observed in infants 7–9 months of age. Being an only child, receiving a complementary food diet, and having socio-emotional disturbances are significant risk factors for infant dyschezia that pediatricians should be aware of.