Neurogenic Bowel Management, Spina Bifida — Children and Adolescents — Clinical Pathway: Outpatient Specialty Care

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

Bowel-management Program for Children and Adolescents (≥ 3 years to 18 years)

70% of patients achieve social continence with retrograde enemas and up to 85% with antegrade flushes.

Goals

  • Daily to every other day bowel movement
  • < 1 bowel accident each month
Fiber
Total Daily Intake Recommendations By Age, Sex:
Ages, years Sex Fiber, grams
4-8 M,F 25
9-13 Males 31
  Females 26
14-18 Males 38
  Females 29
Fluid
Weight Maintenance Fluid Intake Daily
Kilograms Pounds Fluid Ounces Milliliters Cups
15 33 41.5 1250 5
20-30 44-66 50-56.5 1500-1700 6-7
30-40 66-88 56-63.5 1700-1900 7-8
40-50 88-110 63-70 1900-2100 8-9
> 50 > 110 72-80 > 2100 9-10
Toileting
  • Timed seating after retrograde enema (cone, balloon, Peristeen®/Navina®) or antegrade flush (Cecostomy, ACE/MACE) for 30-60 minutes
  • Encourage daily exercise
Cone
  • Basics about Cone Enema: Consists of an enema bag, tubing, and a tip shaped like a cone (also known as a cone stoma irrigator). The cone shape is helpful to maintain a tight seal in cases of poor sphincter tone or patulous anus. Warm water is administered in a retrograde fashion followed by 30-45 minutes of sitting on the toilet for a complete evacuation.
  • The spina bifida healthcare provider may recommend sodium phosphate solution (Fleet® enema) as an additive.
  • Daily enema
  • Fluid volume calculation: 10-20 mL/kg
  • Troubleshooting with Cone Enema
Balloon
  • Basics about Balloon Catheter Enema: 24 Fr. Foley catheter with 30cc balloon is passed transanally about 4-6 inches; the balloon is then inflated (up to 60 cc) then gently pulled back to create a seal. Fluid is administered in retrograde fashion by gravity from enteral-tube feeding bag (e.g., Kangaroo™) with dwell time of 5-10 minutes followed by toilet sitting for 30-45 minutes to evacuate stool.
  • The following additives may be recommended by spina bifida healthcare provider:
    • Polyethylene glycol (PEG)
    • Liquid glycerin
    • Sodium phosphate solution (Fleet)
    • Bisacodyl
    • Mineral oil
    • Castile soap
  • Daily enema
  • Fluid volume calculation: 10-20 ml/kg
  • Troubleshooting with Balloon Enema
Peristeen/Navina
  • Basics about Transanal Irrigation System: Semi-rigid catheter attached to pump tubing that is attached to a bag, filled with fluid. Patient pumps air into bag which is then pressurized so fluid flows through the tubing and out of the catheter, delivering fluid while patient sits on the toilet.
  • No dwell time: once prescribed volume is delivered, the balloon is deflated. Patient sits for 30-45 minutes to evacuate the stool.
  • Begin with daily irrigation. Once soil-free for 30 consecutive days, may switch to every-other-night irrigations
  • Fluid volume calculation: 10-20 ml/kg
  • Note:
  • NO ADDITIVES are recommended
  • Troubleshooting with Peristeen/Navina
Cecostomy
  • Basics about Cecostomy Catheters: Device placed percutaneously through the abdominal wall into the ascending colon. Performed by interventional radiologist with sedation or by surgeon in the OR. It is a 2-step process with a temporary tube placed for 6 weeks followed by a longer-term Chait trapdoor that is low-profile, lying flat against the skin of the abdomen, and is replaced every 6 months. Fluid is administered by gravity in antegrade fashion from enteral tube feeding bag (e.g., Kangaroo) through the delivery device, followed by toilet sitting for 30-45 minutes to empty colon.
  • Daily Irrigation
  • Fluid Volume Calculation: 10-20 ml/kg
  • The following additives may be recommended by spina bifida healthcare provider:
    • Polyethylene glycol (PEG)
    • Liquid glycerin
    • Sodium phosphate solution (Fleet)
    • Bisacodyl
    • Mineral oil
    • Castile soap
  • Troubleshooting with Cecostomy
ACE/MACE
  • Basics about Malone Antegrade Continence Enema (ACE/MACE): Surgical procedure in the OR where the appendix or a part of the intestine is brought to the level of the skin of the abdomen, creating a stoma that is easily accessed with a standard straight catheter. Following surgery, a catheter is left in place for 2-3 weeks while the surgical site heals. An “ACE stopper” may need to be placed in the channel for a few months after surgery. A lubricated catheter is passed once daily through the channel. Fluid is administered by gravity in antegrade fashion from an enteral tube feeding bag (e.g., Kangaroo) followed by toilet sitting for 30-45 minutes to evacuate stool.
  • Daily irrigation
  • Fluid volume Calculation: 10-20 ml/kg
  • The following additives may be recommended by spina bifida healthcare provider:
    • Polyethylene glycol (PEG)
    • Liquid glycerin
    • Sodium phosphate solution (Fleet)
    • Bisacodyl
    • Mineral oil
    • Castile soap
  • Troubleshooting with ACE/MACE
Indications for Abdominal X-ray
  • Suspicion of overflow encopresis or impaction
Indications for Surgical Referral
  • Constipation despite adherence and maximized treatment
  • Desire for independence in bowel management