A survey of bowel washout practice in children with neuropathic bowel in the UK and Ireland
Authors: David Marshall, Laura Connolly, Emma Kelly
Background
Most children with spina bifida require medical intervention to
achieve social faecal continence. Bowel washouts can be
delivered retrogradely (per rectum) or via an Antegrade Continence
Enema (ACE) stoma. We wished to ascertain the spectrum of
practice nationally, and if there was an optimum regimen.
Materials and Methods
Continence Nurse Specialists from a broad sample of paediatric
tertiary-referral units completed an on-the-spot questionnaire on
their bowel washout programme.
Results
Eleven units across England, Scotland, Wales, Northern Ireland
and the Republic of Ireland were surveyed. Each department
supervised between15-350 (mean = 83, total > 910) children on
bowel washouts for various conditions, of which spina bifida was
the commonest.
Some units employed a washout volume of 20 mL/kg body weight,
and others a fixed volume for all children, which ranged from 100 -
1000 mL. Almost all departments added salt to tap-water to
approximate an isotonic solution. The vast majority of units
also prescribed in the washout a laxative (bisacodyl,
macrogols/polyethylene glycol, phosphate, sodium citrate, sodium
picosulphate, or liquorice-root in reducing order). Some
departments omitted the laxative, or lowered its dose, when
starting a child on a washout programme, in an attempt to reduce
off-putting side-effects. A selection of devices were used to
administer rectal washouts, the commonest being a graduated-cone
with gravity-feed irrigation-bag, or the Peristeen balloon-catheter
system (Coloplast).
The most frequently reported side-effect was abdominal cramping,
which tended to occur more often with bisacodyl or phosphate,
especially at higher doses or if very constipated. The
estimated time spent on the toilet after administration of the
washout varied from 30 - 90 (median = 45) minutes, and seemed to be
independent of the washout volume or composition. All units
started with a daily washout, and most gradually lengthened the
interval between washouts to every other day, or even to twice per
week, until soiling recurred. There was a general impression
that bisacodyl was the most productive aperient.
The commonest complaint from children (regardless of age) and
parents alike was the time commitment. However, most users
felt that this was balanced by the time saved no longer having to
deal with faecal incontinence.
Conclusions
A diverse range of regimens was reported, suggesting that no
ideal one exists for all children. Bisacodyl appears to cause
more cramping, but is probably the most efficacious laxative
additive, so may reduce the weekly-time spent on the toilet, which
is the biggest issue for families.
Dept. of Paediatric Surgery, Royal Belfast Hospital for Sick
Children, 180 Falls Road, BELFAST, N. Ireland, BT12 6BE,
UK
E-Mail: david.marshall@belfasttrust.hscni.net
