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 patient populations: anorectal malformation, idiopathic constipation, and Hirschsprung disease patients with intact anal canal who suffer from constipation

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

Fiber (pectin or Citrucel) is added to give bulk to stool, especially important for anorectal malformation patients who are sensitive to liquid stool and cannot control it

During the one-week dose-finding period, if the patient does not have a bowel movement within 24 hours, an enema is given to empty the colon and the laxative dose is increased

In Hirschsprung disease, contrast enema shows a non-dilated colon followed by a dilated portion, whereas idiopathic constipation shows dilation all the way down into the pelvis

Laxatives should never be given to fecally impacted patients because they will experience severe cramping and likely not return for treatment

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

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

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

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

When patients have normal sacrum, good operation, and constipation, suspected incontinence may actually be pseudo-incontinence, warranting a laxative trial

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

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

The timing of X-ray within the 24-hour period affects interpretation, as patients may have 12 hours remaining to produce additional stool

Bowel management protocols 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 patients at pull-through network meetings is associated with continence problems and more frequent stools

Senna is not recommended for young children in Spain due to concerns about causing cathartic colon, though the Spanish center uses it without observed side 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 life easier as the child grows and appears to produce better 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 one of the best factors for success in bowel management because of the relationship built and ongoing support provided