This document provides advice for bowel continence in children with Spina Bifida. It discusses establishing regular bowel movements, dietary changes to prevent constipation, and habit training using toilet sitting. For children where these initial approaches are ineffective, it recommends adding stimulant laxatives or cleanout methods. It also describes the ACE procedure which uses the appendix to construct a conduit for administering antegrade enemas when other options have failed. The goal is to establish an individualized bowel management program for independence.

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