Management of the Neurogenic Bowel Jacki Frost RNC, CWS Shriners Hospitals for Children Tampa, Florida

BOWEL MANAGEMENT Most children with spina bifida need assistance with bowel continence The goal is to have one BM a day on the toilet at an appropriate time

CONTROL CENTERS

BOWEL MANAGEMENT

GOALS Non constipated stool Social continence by school age Independence

WHERE TO BEGIN? Prevent constipation Toilet sitting when developmentally appropriate

WHERE TO BEGIN? Track bowel movements Time of day Number per day

CONSISTENCY TOO FIRM TOO SOFT

WHERE TO BEGIN?

BOWEL MANAGEMENT Multiple therapies available Trial and error approach Start simple and work up to the more complex Goal is to have the child be independent in the program

DIETARY IMPACT Fiber and fluids are key to success Infants: water in between formula feeds

DIETARY IMPACT Mix prune juice with apple juice Add fiber supplements

DIETARY IMPACT Toddlers: encourage raw fruits and vegetables “Finger foods”

DIETARY IMPACT Most toddlers like foods that cause constipation –Peanut butter –Milk –Cheese –Mac and cheese

DIETARY IMPACT

WHERE TO BEGIN? Fiber supplements Many different brands Check with your physician before giving to infants

WHERE TO BEGIN? Infants Prevent constipation –Fruit –Fruit juices –Water –Fiber additives

TIMING

WHERE TO BEGIN? Toddlers Prevent constipation Start toilet sitting –15-20 minutes after eating

WHERE TO BEGIN? Sit with feet well supported Grunt or bear down Blow bubbles or pinwheel

WHERE TO BEGIN? This approach is called habit training Pick a time that works for you

WHERE TO BEGIN? Older child Use the reward system Sticker chart with a prize

BOWEL MANAGEMENT Start with an assessment of current schedule Bowel tracking noting: –Frequency –Consistency –Pattern –Incontinence Start young assessing for constipation

NEXT STEPS If habit training alone is not effective? Add stimulants

STIMULANTS Oral Rectal: –Enemas –Suppositories

STIMULANTS

Choose those that: Do not cause cramping Are palatable Are predictable

BOWEL MANAGEMENT

CONE enema Enema tubing has a cone which holds fluids in the rectum Sit on toilet to do program Older children can perform independently

CONE ENEMA

CLEANOUTS

Oral agents alone In combination with enemas

CLEANOUTS Miralax Takes 5-8 days to begin working Massive results Not predictable for maintenance

CLEANOUTS Milk of Magnesia Large dose over a short period of time Works in 48 hours or less May cause cramping Difficult to deliver

ACE PROCEDURE Antegrade Continence Enema Also known as MACE (Malone Antegrade Continence Enema) Indicated when all other approaches have failed

ACE PROCEDURE A tube like structure is created from the appendix The tube goes from the ascending colon to the right lower abdominal wall Enemas every three days empty the colon completely

In patients with intractable fecal incontinence The Mitrofanoff principle used to construct a continent conduit to the bowel (MACE) ACE PROCEDURE

Enemas in an antegrade fashion into the cecum to clean out the large bowel

ACE PROCEDURE Challenges Volume needed to clean out Length of time to perform

ACE PROCEDURE Using the MACE procedure fecal continence rates and satisfaction have been reported approaching 100%

BOWEL MANAGEMENT

Each child should have an individualized program Trial and error until success