Pediatric Bowel Programs

Posted by Nurse Linda in Life After Paralysis on July 01, 2020 # Health

Bowel programs are critical to the health of all individuals with spinal cord injury from disease or trauma. There are possible challenges with bowel function at each step of your child’s development due to SCI. For babies, the bowel program might be overlooked, school age should learn to conduct their own program and teens might object to the process. Creating an effective bowel program takes support from the parent or caregiver and healthcare providers.child at school

Bowel programs for the youngest of the community varies. This group includes newborns to the underage two group. Unfortunately, these infants are often sent home without any care for the bowel. This is because until age 2, the sphincters that control bowel movement are not yet under the control of the child. The resulting theory, by some, is that since there is no control of the bowel and since babies wear diapers anyway, to just let nature take its course and let stool be expelled as it happens. Often, this continues through ages 4 and 5 and at times even older.

But there are complications that can result from this process. With spinal cord injury from trauma or disease, the bowel can be extremely slow. This leaves stool to collect within the entire length of the bowel becoming difficult to pass, causing cramps or colic, creating impaction or hard stool blockage, triggering autonomic dysreflexia (AD) and over stretching the walls. All these issues make the bowel less functional in the future.

Children with spinal cord injury have nerves affected that control the bowel thereby affecting the digestive process. The bowel is slowed. When the nerves are affected, the diagnosis is neurogenic bowel. Constipation is hard stool that is difficult to pass. In constipation, the nerves are not affected.

Many people will call neurogenic bowel constipation, but it is not. After a spinal cord injury, neurogenic bowel or nerve dysfunction is the source of the problem. There are treatments for neurogenic bowel which are presented here. A child with neurogenic bowel can also have constipation but it is important to know these are two distinctly separate issues. Treatment for constipation will not help a neurogenic bowel.

In spinal cord injury for disease or trauma, there are two types of issues affecting the bowel. Higher level injuries in the cervical (neck) or thoracic (rib cage) areas result in an Upper Motor Neuron (UMN) injury. UMN injury results in tone or spasticity in the body below the level of injury. Tone is easy to see in the limbs, but tone is likely also internally, in the torso which can affect the stomach and bowel, impairing digestion. A Lower Motor Neuron (LMN) injury occurs in those with injury to the lumbar (lower back) or sacral area (end of the spine.) LMN injuries result in flaccid limbs and flaccidity affects in internal organs. With many diseases of the spinal cord and even in some traumatic accidents, a combination of both can occur.

UMN and LMN injuries affect the bowel. UMN creates a bowel function where small amounts of stool are uncontrollably expelled whenever there is a spasm in the bowel. The bowel does not completely empty but stool will remain in the lower bowel which can become hard, difficult to pass or even cause a blockage in the bowel.

Stool in the bowel of a child with an UMN injury can trigger autonomic dysreflexia (AD), an emergency of increased blood pressure to dangerous levels. More about AD can be found here.It is critically important that you review this information if your child has a spinal cord injury at any level but especially at cervical or thoracic levels. AD is a medical emergency that you will need to know about should it occur.

In the case of an LMN, the bowel is flaccid or without tone. Stool cannot be effectively propelled through the bowel nor can it be evacuated. The stool collects in the bowel with the results of either over stretching the bowel or sometimes some of the stool will be expelled through the area of least resistance which is through the rectum. With LMN injury, stool will not be completely evacuated. Remaining stool will become hard, unable to be passed. The bowel will overstretch.

In either case, UMN or LMN injuries, stool is not evacuated from the lower bowel as it should. The inefficient evacuation can lead to medical complications early on or significant issues as your child grows due to the over stretching along the entire bowel. The bowel is like a balloon. The bowel can stretch to accommodate stool but as stool continues to collect, it will overstretch the delicate bowel wall. Over time, the elasticity of the bowel wall can have difficulty regaining its former shape. Ongoing overstretching can affect the bowel far into adulthood.

In addition, an over stretched bowel can develop diverticula, or small out pouches in the bowel wall. Internal hemorrhoids can form. Fissures can occur. All these bowel issues can lead to pain, over collection of stool, infection, or rupture. Your child may not feel pain, but their bodies will react to it in different ways.

Bowel programs can be performed with children to avoid these complications. There are several elements to the bowel program. These include what goes into the body and how to get it to come out effectively.

First, think about what goes into the body, both fluid and foods. Fluid needs to be provided for hydration. It is an essential treatment for the bowel program. Stool needs to be moist to pass through the body. Stool that is too dry is hard to move along in the gut. Dry stool is constipated stool. The muscles of the abdomen have difficulty in passing hard stool.

If your child’s nutrition is breastmilk or formula, that is all they should be taking in. As they grow and switch to table food, water can be added in addition to milk. Still later, juice, with reduced sugar content might be used. Avoid drinks that contain caffeine or too much added sugar or sugar substitutes such as soda and energy drinks. These drinks can still be had but reserve them for special treats, not daily. Older children might experiment with alcohol which dehydrates the body including the stool.

Ask for a consult with a dietitian, hopefully one with experience with children who have a spinal cord injury to ensure an adequate number of calories without being too much due to decreased movement. You will want to develop a strong relationship with the dietitian so you can get advice in advancing your child’s diet as needed.

Foods need roughage to help them pass through the gut. There are formulas that are available with added fiber. Be sure to discuss adding fiber to the infant’s diet with their healthcare professional to make sure it is right for them. The younger the gut, the more agile it is so you might not need to add fiber but keep the idea in reserve in case you do.

As your child ages, check into fiber products as needed. Some children do not require extra fiber, others do. Your health care provider will assist with fiber products (opt for sugar free to avoid too much sugar in the diet). There are drinks, powders, and cookie formulations.

Stool softeners may also be needed. Report the consistency of stool. If the stool is hard with lumps, it needs fiber and softeners. Mushy stool will not require softeners, but fiber can bulk it up to make it easier to pass.

Movement affects everyone’s bowels. As people walk or exercise, their leg muscles stimulate the abdominal muscles. This helps stool move along in the bowel. If your child does not have movement in their lower body, provide it to them in the form of range of motion exercises. This greatly helps stool move along in the bowel.

At the end of the gut is the rectum. The end of the bowel has a collection area for stool to be gathered prior to expulsion. Stool can get caught here due to spinal cord injury. For stool to be expelled, there are two sphincters that must open. You can see the external sphincter because that is the rectal opening. The internal sphincter cannot be seen as it is higher in the bowel from the rectum. The internal sphincter needs to relax to allow stool to be expelled. In an UMN injury, this sphincter is not receiving communication from the brain to open. In UMN injury both rectal sphincters can have tone (spasticity) leading them to remain closed.

The LMN injury has flaccid sphincters, meaning they are loose. Stool will need to be manually removed from the lower bowel.

The goal of a bowel program is to open the rectal sphincters and stimulate the bowel so stool can be expelled. To do this for a child with an UMN injury, a suppository is inserted. In infants and small children, a glycerin suppository is used because it is gentle in action. In infants, the glycerin suppository is cut into fourths, lengthwise which provides more surface area to interact with the bowel.

The person performing the bowel program gently inserts one fourth of the glycerin suppository using lubricant with their gloved small finger. The suppository must be placed against the wall of the bowel to work. Inserting in the center of stool does not allow the suppository to melt by body heat nor to stimulate the bowel to work. Digital stimulation can be performed again using the lubricated small finger in a very slow and gentile narrow rotation. Stool will be expelled from the bowel. Children with an LMN injury require a manual evacuation of the bowel using a well lubricated, gloved small finger.

As the child grows and develops, the amount of suppository can be increased to one half or more of the lengthwise cut glycerin suppository. When the child is much older, you might want to switch to a Dulcolax or magic bullet suppository. Digital stimulation should be done with the index finger as your child grows. The internal sphincter is located about the same distance in the bowel as the child’s index finger length. Look at the length of your child’s index finger to assess where the internal sphincter would be for digital stimulation.

Generally, enemas and laxatives are not used as they do not stimulate the bowel to work in its natural function. Overuse of enemas can create a situation where the bowel loses more function or eventually could even stop working. There is an exception with the Enemeez small enema for older children as it is such a small amount of enema solution that it works only in the lower bowel.

When the child is able to sit, have them sit on a potty for evacuation of stool. You may need to adapt a child’s potty so they can sit. Pay careful attention to sitting pressure areas. Gravity aids tremendously in this process. Younger children can be held in your arms upright and use a diaper. Older children should use the toilet or commode with adaptions appropriate for their needs.

In the older child, the bowel program is done every day to every other day depending on their needs. You will need to discuss frequency of a bowel program for infants and young children with their health care provider.

Bowel programs are developed to protect the bowel function but more importantly so the individual does not have accidents that can be socially embarrassing especially for children and adolescents. The bowel program should be in place and functioning by the time the child goes to school to avoid incontinence of stool. At the time of toilet training, start explaining what you are doing in the bowel program. Have the child participate as they are able. The goal is to have your child independent in bowel functioning by the time they enter school.

It is a child’s rite of passage to be independent in toileting. It can be a challenge to help your child to independence because let’s face it, every parent wants to do everything for their child. Toileting is a normal part of development. Your child may toilet differently than you, but this is their system so encourage independence. Your attitude will be mimicked by your child. Helping them achieve independence in toileting is a start to their maturity. Nurse Linda

Linda Schultz, Ph.D., CRRN, a leader and provider of rehabilitation nursing for over 30 years, and a friend of the Christopher & Dana Reeve Foundation for close to two decades. Within our online community, she writes about and answers your SCI-related healthcare questions in our Heath & Wellness discussion.