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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