Laxative for Bowel Management: Pediatric Bowel Management 2013

85% of pediatric patients respond to the Cincinnati laxative-based bowel management protocol.

The protocol is used for three main populations: patients with anorectal malformation, idiopathic constipation, and Hirschsprung disease patients with intact anal canal suffering from constipation.

Contrast enema in idiopathic constipation shows dilation all the way down into the pelvis, distinguishing it from Hirschsprung disease which shows a non-dilated segment followed by dilation.

Laxatives should never be given to fecally impacted patients because they will experience severe cramping and may not return for care.

The disimpaction protocol uses 3 enemas per day for 3 days, combining normal saline with fleet, glycerin, and soap on successive days.

Laxatives are only used in patients who are continent or have potential for bowel control; incontinent patients receive only enemas.

If abdominal X-ray after 3 days of enemas still shows impaction, the patient is admitted for nasogastric tube and GoLYTELY solution for 2 days.

So-called incontinence in patients with normal sacrum and good operation may actually be pseudo-incontinence due to constipation, warranting a laxative trial.

Disimpaction under anesthesia is required in approximately one patient per year at Cincinnati Children's Hospital.

Laxatives and enemas should never be mixed because the purpose of bowel management with enemas is to clean the colon and maintain it quiet for 24 hours until the next enema.

Senna laxative is preferred because it is more predictable and acts as a stimulant.

During the one-week titration period, if the patient does not have a bowel movement within 24 hours, an enema is given to prevent re-impaction.

Fiber (pectin or Citrucel) is added to provide bulk to stool, especially important for patients with anorectal malformation who cannot control liquid stool.

Liquid stool in the presence of solid stool on X-ray indicates paradoxical diarrhea, where liquid stool passes around formed stool.

The timing of abdominal X-ray within the 24-hour period affects interpretation; a patient may have 12 hours remaining to produce additional stool after the X-ray is taken.

Laxative-based bowel management can work in children with Down syndrome and other syndromic conditions, but may require waiting until the child is more developmentally mature and invested in staying clean.

MiraLax use in post-operative anorectal malformation patients tends to cause problems with continence and more frequent stools.

In Spain, senna is not recommended for young children due to concerns about causing cathartic colon, but the speaker's center uses it without observed adverse effects.

Children should learn to self-administer enemas before puberty to respect their privacy as they mature.

Starting bowel management protocols as early as colostomy closure makes adaptation easier as the child grows and appears to improve results.

Gastric electrical stimulation for gastroparesis has been observed to increase stool frequency in some patients, though the mechanism is unknown and may involve neurofeedback loops.

Having a primary nurse or dedicated patient nurse is beneficial for bowel management success because it builds a relationship and provides consistent support through the iterative adjustment process.