Bowel Management Program
The Bowel Management Program is a week-long program for children dealing with constipation and the inability to control stool when it needs to stay inside or leave the body. This is called fecal incontinence, soiling, or having “an accident.” Most patients that enter the Bowel Management Program experience incontinence issues related to:
- Previously repaired anorectal malformations or Hirschsprung disease
- Spinal or sacral disorders that affect the bowel (spina bifida, myelomeningocele, absent sacrum, sacrococcygeal teratoma)
- Motility disorders and those with severe constipation (encopresis)
Patients and families will end the week equipped with:
- An understanding of how continence works
- Information on why some children soil
- A customized, and proven, treatment plan for each child
The Bowel Management Program is offered in a variety of levels of interaction: in-person, hybrid and fully remote. Please contact us to discuss with our team what option will be best suited for you and your child.
We are continuing to offer our fully in-person Bowel Management Program for new and established patients. The in-person Bowel Management Program includes three in-person visits with your provider. All imaging will be completed at Nationwide Children’s. You will also have daily interaction with your team.
Our hybrid Bowel Management Program is for new or established patients. We will see your child for one in person office visit at the beginning of the week on either Thursday or Friday, depending on which provider your child will see. You and your child can then go home for the remainder of the week. You will have a telehealth (phone or Zoom) visit with your provider on Monday and Friday of the second week. You will obtain abdominal films at your local facility and send the imaging to our team for review throughout the week. You will also still have daily interaction with your team.
Our remote Bowel Management Program is for established patients only. You and your child do not need to travel to Nationwide Children’s Hospital as all visits will be done remotely. Testing prior to and during the week can be completed at your local facility. Your child will have a telehealth visit (phone or zoom) depending on which state you live in on Monday and Friday. You will obtain abdominal films at your local facility and send the imaging to our team for review throughout the week. You will also still have daily interaction with your team.
Bowel Management Treatment Options
The Bowel Management Program is a custom set of treatments designed to keep your child free from stool accidents, so that he or she may be able to wear normal underwear and participate in normal activities. The Bowel Management Team will work together to decide the best treatment for your child. This treatment will depend on the type of bowel problem your child has. There are two main treatments used during the Bowel Management Program:
The enema program is used for children who cannot control his or her own bowel movements right now. This is usually related to an anorectal malformation, Hirschsprung disease or a spinal condition. An enema is a safe liquid that can help to clean the stool out of your child’s bowel. The liquid will run through a tube that is inserted in your child’s rectum. The liquid may also run through a Malone or cecostomy, if one is present.
The goal of the enema is to clean the colon or bowel, which then keeps the child clean from accidents and fecal soiling for 24 hours after it is given. The enema is given every day of the Bowel Management Program in the later afternoon or evening. Participants are asked to keep a daily record of how the enema worked. When the right dosage is found, the child will continue to receive the daily enemas so he or she can stay clean and wear normal underwear.
The enema process takes about one hour, start to finish, every day. This includes five to 10 minutes for the solution to stay in the colon and 45 minutes for the child to sit on the toilet to completely empty the colon.
The medicine program is used for children whose bodies do not know how to control his or her own bowel movements right now. However, these children have all of the elements to stay clean. This is usually caused by a slow colon (hypomotility issue), that results in constipation.
The built-up stool stretches the nerves in the rectum that sense when it is time to have a bowel movement, so that they do not work normally. The stool will stay in the same place because the bowel is not moving it downward. Laxatives help make the bowel move again so that the build-up of stool can leave the body. With regulation of this, children can learn to have bowel control.
The medicine program may include a combination of:
- Laxatives
- Fiber
- A special diet
The goal is to combine these three things to help the child have one to two well-formed bowel movements per day. Using this program, successful toilet training is possible.
Laxatives
During the Bowel Management Program, the provider orders a certain amount of laxative for the child to take based on the size and speed of the colon. The provider may order different kinds of laxatives at different doses to see what works best for the child. The key active ingredient most commonly used is senna. You should always know the milligrams of senna needed. the child will, most likely, not need enemas. If the provider does order an enema, it is usually to remove the built-up stool. It is very important that the bowel is empty when starting the program. This will ‘reset’ the bowel to empty every 24 hours. More laxatives will probably be ordered. If the child is having diarrhea and loose stools, fewer laxatives or more fiber will probably be ordered. The goal is to make the stool the right consistency, so the child can achieve success with toilet training.
Fiber
The provider also orders water-soluble fiber to be mixed in the child’s food or drinks. Water-soluble fiber helps to make the laxative work better by binding watery stools together, without causing constipation.
For children with both mechanical and medical bowel problems, treatment may be based on the speed with which your child’s bowel moves. For patients in either program, the bowel may move too slow or too fast. When the bowels move too slow, it is called hypomotility. When they move too fast, it is called hypermotility. Both of these can cause your child to have problems with toilet training. Often, elements of both the Enema and the Medicine program are combined for the best results.
What To Expect During the Bowel Management Program Week
The week starts with an informational parent lecture that outlines the week including goals and expectations of patient outcomes based on diagnosis. At the beginning of the week each patient has a clinic visit, zoom visit, or telephone call with a colorectal surgeon or advance practice provider (nurse practitioner or physician assistant). This visit is preceded by a contrast enema to determine the anatomy of the colon. The patient and family will be given their treatment plan for the week at the first visit based on diagnosis, symptoms, and previous treatments.
The remaining days of the week the patients will obtain an abdominal X-ray and send in a report of the effects of their current treatment plan including number of stools, any soiling, or any adverse side effects. The team of colorectal surgeons and advance practice providers (APPs) meet each day to review the X-rays and parent reports. The team determines the patient’s plan for the next day and it is then communicated back to the parent by their team nurse clinician.
The patients have another visit on Monday after obtaining their daily abdominal X-ray. The last day of the program is a final visit where the patient is sent home with a successful daily bowel regimen that empties their colon and keeps them clean. During the week there are parent and patient support groups led by our psychosocial team. The patients and family also have the opportunity to see a pediatric psychologist during the week.
Each patient is sent home with a follow up plan to ensure continued success of the regimens prescribed. The follow up schedule after a bowel management week includes a one-month and three-month follow-up with abdominal X-rays. These follow ups are completed either in clinic or over the phone with a nurse practitioner. If the patient is successful at the three-month follow up, the patient is then set up for annual clinic visits with abdominal X-rays. The family is encouraged to contact the center to speak with their assigned nurse clinician any time after the bowel management week for any questions or concerns with the regimen.
Tips For Success
The success of this program depends on everyone working together. There has to be a partnership between the family, the child and the healthcare team. Successful bowel management will result in a complete life change for our patients and their families, and our team is dedicated to helping your child achieve this success.