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from Sumer 1997 issue

Spina Bifida: Managing Bowel Dysfunction in the School-Aged Child

by Brenda Benner, Health Center Supervisor, TSBVI

Spina Bifida is a condition in which the vertebra fails to close at some point along the spine. The term "spina bifida" may include a closed lesion (spina bifida occulta) or open lesion (meningocele and myelomeningocele). Many other conditions can happen with this problem such as hydrocephalus, bowel or bladder dysfunction, and paralysis and lack of sensation below the level of the lesion. Each of these conditions may lead to its own set of problems, including visual impairment, bowel or bladder incontinence, deterioration in renal function, lack of mobility, and skin breakdown. Families, in conjunction with their primary care provider and school nurse, play a major role in the prevention of complications and the promotion of health and positive self-esteem in the child with spina bifida.

Bowel and bladder complications usually occur with myelomeningocele. Even myelomeningoceles in the low lumbar and sacral areas have some degree bowel or bladder dysfunction because the nerves from this area supply those organs. There are physical problems associated with bladder incontinence, but the emotional issues related to bowel control with the associated, odor, lack of positive self-esteem, and poor body image can lead to severe social problems.

Bladder incontinence is approached mostly by a medical model. Prevention of recurrent bladder infections is primary as kidney failure can cause death. Bowel training is not life threatening, and has more of a behavior management approach. Fecal incontinence in the school setting can be morally devastating to a school-aged child.

Setting up a successful bowel management program can be one of the most important things in your child's life. Remember that no single thing works, and patience is needed to find the right combination. Before starting a program simple documentation of "how" and "what" is happening with your child's bowel movements (BM's) is important. For at least a week note when and how (in toilet, or diaper, after enema or suppository, or set on toilet without results)your child has a BM. Note the consistency of the stool (hard like pebbles, soft and formed, or runny and loose). This information and the support of your medical resources should enable you to develop a bowel management program with the following guide.

Stool consistency: Your child's stool should be soft and formed like clay, not like hard rocks or watery. To get the consistency right give your child high fiber foods and at least 6 glasses of water or juice a day. Greasy foods or candy can cause accidents. Try to have the "right" foods available such as fruit or bran muffins. We have found that mixing grape juice with prune juice makes it more palatable.

Schedules for meals and toileting: Remember the colon is one of the most "regular" parts of the body. Your child should eat meals at about the same time every day (parents of diabetics learn to live with this rule strictly) and sit on the toilet after the same meal everyday. They should sit with their feet on the floor or on a footstool. While trying to have a BM have your child bear down, push on lower abdomen, cough, strain, laugh, blow, use digital stimulation, and ANYTHING that helps.

The body may need external interventions at first to get the schedule started. These interventions include:

As with any behavior program, praise your child for doing well. Talk to your child before the program, and let them know that you will work together to help him stop wearing diapers. Get out that old star chart, or make a new one. Other targeted behaviors should be put on hold during this intense training period. Young children should earn prizes from a treat box. As successes begin wean the treats to longer accident free periods. If your child has an accident, support them and focus on tomorrow.

Sometimes this program takes awhile, but it is worth it. Do not hesitate to enlist the help of your school nurse, as bowel continence is so important to your child. Pay attention to diet, water, and exercise and focus on stool consistency and work on timing. The following is a good recipe:

"Six Week Muffin"

Mix dry ingredients in a very large mixing bowl. Set aside. Mix together oil and sugar; add eggs and mix well. Add buttermilk. Add liquid to dry ingredients; mix well. Store in covered container in refrigerator and use as desired. To use, fill greased muffin pans 2/3 full. Bake at 400 degrees for 15-20 minutes. Batter will keep in refrigerator for six weeks.

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from Sumer 1997 issue

Last Revision: July 30, 2002

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