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