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

2. 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

3. CONTROL CENTERS

4. BOWEL MANAGEMENT

6. GOALS Non constipated stool Social continence by school age Independence

7. WHERE TO BEGIN? Prevent constipation Toilet sitting when developmentally appropriate

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

9. CONSISTENCY TOO FIRM TOO SOFT

10. WHERE TO BEGIN?

11. 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

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

13. DIETARY IMPACT Mix prune juice with apple juice Add fiber supplements

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

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

16. DIETARY IMPACT

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

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

19. TIMING

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

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

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

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

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

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

26. STIMULANTS Oral Rectal: –Enemas –Suppositories

27. STIMULANTS

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

29. BOWEL MANAGEMENT

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

31. CONE ENEMA

32. CLEANOUTS

33. Oral agents alone In combination with enemas

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

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

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

37. 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

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

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

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

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

42. BOWEL MANAGEMENT

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