Neurogenic Bowel Management, Spina Bifida — 6 months, Toddlers up to 36 Months — Clinical Pathway: Outpatient Specialty Care

Neurogenic Bowel Management, Spina Bifida Clinical Pathway — Outpatient Specialty Care

Bowel-Management Program: Infants > 6 months and Toddlers up to 36 Months

  • The majority of patients in this age group respond to oral medications and a high-fiber diet.
  • Allow a minimum of 2 weeks for adjustments in treatment and ensure adherence.
  • Timed sitting is important to develop comfort with toileting habits.
  • A good bowel regimen is essential to prevent UTIs and diaper dermatitis.

Goals of Bowel Management Program

Bristol Stool Scale types 3-6

Fiber
  • RN to review Fiber Patient Instructions
  • Total Daily Intake Recommendations By Age:
    • 0-6 months: breast milk, formula
    • 6-12 months: recommended “p” foods
      prunes, peaches, pears, plums, peas
    • 1-3 years: 19 grams
Fluid
(Daily minimum fluid intake)
Weight Maintenance Fluid Intake Daily
Kilograms Pounds Fluid Ounces Milliliters Cups
4.8-10 10.5-22 16-33.5 480-1000 2-4
10-20 22-44 33.5-50 1000-1500 4-6
15 33 41.5 1250 5
Toileting
  • Timed Seating > 2 years
    • After meals to stimulate gastrocolic reflex
    • Time as tolerated by patient
Medications
  • Maximize oral laxatives, then add suppository or enema as needed
  • Consider overflow encopresis for constipation alternating with diarrhea
Lactulose 1.5-3 mL/kg/day (1-2 g/kg/day) divided into 2 times/day
MAX dose: 60 mL/day (40 g/day)
Polyethylene glycol (PEG 3350) 10-19 kg: 1/2 cap daily
≥ 20 kg: 1 cap daily
Senna 1 month to 2 years:
  • Syrup dose 1.25-2.5 mL (2.2-4.4 mg) daily
  • MAX dose: 5 mL (8.8 mg sennosides)/day
Glycerin suppository 2.8 g (4mL) daily as needed
Docusate DocuSol Kids Docusate 100 mg (contents of one mini-enema) daily as needed
Pediatric Fleet Enema For patients > 2 years of age 1 as needed, 1-2 times per week
Additional Considerations for Changing Bowel Regimen
  • Transition from breast milk to formula and addition of solid foods may exacerbate constipation
  • Consider:
    • Increase in oral laxative
    • Addition of a liquid glycerin suppository as needed
    • Overflow encopresis may be due to significant stool burden
  • May require escalation of treatment:
    • GI infection
    • Antibiotics, anticholinergics, opioids, antihistamines may affect transit time
    • Recent surgery
Indications for Abdominal X-ray
  • Suspicion of overflow encopresis
Indications for Surgical Referral
  • Constipation despite adherence to program and maximized treatment