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

Management of the Neurogenic

Bowel

Jacki Frost RNC, CWSShriners Hospitals for

ChildrenTampa, 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

BOWEL MANAGEMENT

GOALS

• Non constipated stool

• Social continence by school age

• Independence

WHERE TO BEGIN?

• Prevent constipation

• Toilet sitting when developmentallyappropriate

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

STIMULANTS

Choose those that:

• Do not cause cramping

• Are palatable

• Are predictable

BOWEL MANAGEMENT

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

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

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

BOWEL MANAGEMENT

• Each child should have an individualized program

• Trial and error until success