Management of the Neurogenic Bowel

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

5. 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 SOFT TOO FIRM

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

29. BOWEL MANAGEMENT

30. 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

31. CONE ENEMA

32. CLEANOUTS

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

39. ACE PROCEDURE • 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. BOWEL MANAGEMENT • Each child should have an individualized program • Trial and error until success