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Management of the Neurogenic Bowel

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

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Management of the Neurogenic Bowel

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  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

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