A survey of bowel washout practice in children with neuropathic bowel in the UK and Ireland

Abstract

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. Conclusion: 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.