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

1. Advice for Bowel continence for Spina Bifida in
Children
Learn more about Spina Bifida at
http://www.spinabifida.net

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 FIRM
TOO SOFT

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

44. Questions?
• For more educational resources about Spina Bifida please visit
http://www.spinabifida.net