Advice for Bowel continence for Spina Bifida in Children

Learn more about Spina Bifida at http://www.spinabifida.net

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 MANAGEMENTMultiple 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 IMPACTMost 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 MANAGEMENTStart 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

CLEANOUTSMiralax

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

ACE PROCEDURE

• 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

BOWEL MANAGEMENT

• Each child should have an individualized program

• Trial and error until success

Questions?• For more educational resources about Spina Bifida please visit

http://www.spinabifida.net